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1 



DISEASES OF THE NOSE AND THROAT 



KNIGHT 



DISEASES 



NOSE AND THROAT 



CHARLES HUNTOON KNIGHT, A.M., M.D. 

PROFESSOR OF LARYNGOLOGY CORNELL UNIVERSITY MEDICAL COLLEGE, SURGEON 

MANHATTAN EYE AND EAR HOSPITAL, THROAT DEPARTMENT ; MEMBER OF 

THE AMERICAN LARYNGOLOGICAL ASSOCIATION, OF THE AMERICAN 

MEDICAL ASSOCIATION, OF THE AMERICAN ACADEMY OF 

MEDICINE, OF THE AMERICAN THERAPEUTIC SOCIETY, 

OF THE NEW YORK ACADEMY OF 

MEDICINE, ETC. 



147 ILLUSTRATIONS 




PHILADELPHIA 

BLAKISTON'S SON & CO 
101 2 Walnut Street 
1903 






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PREFACE. 

The contents of the following pages have formed the basis of a 
course of lectures at Cornell University Medical College and have 
been arranged chiefly for the convenience of students. 

It has been thought best to include only the essentials of anatomy 
and limited space has compelled the omission of bibliographical ref- 
erences. The details of anatomy may be found to better advantage 
in special text books. The intention has been to give credit in every 
instance to original sources, but the growth of the literature of the 
subject has been so extensive that a separate volume would be re- 
quired to contain a complete list of authorities. 

The author desires to express his indebtedness to his colleagues 
for many courtesies and suggestions and the hope that the statement 
of his opinions has been accomplished with clearness and without 
excessive dogmatism. 

In these days of change and progress it is easy to find many ques- 
tions to which it is unsafe to give a final and positive answer. 
Even the accepted views as to the physiology of the larynx and the 
action of the vocal bands are likely to be amended in the light of 
recent interesting researches. Theories of nasal pathology, the 
innervation of the larynx, the whole subject of therapeutics of the 
upper air track are in a state of unrest which offers a wide field for 
investigation. It is becoming to approach the study of these matters 
with an open mind, being prepared at all times to discard the old 
and test the new. With this spirit this volume is presented in the 
hope that it may be of some service to seekers after truth. 



CONTENTS. 



CHAPTER I. 
Anatomy and Physiology of the Nasal Passages. Methods 

of Examination. Instruments and Apparatus iy 

CHAPTER II. 
Acute and Chronic Rhinitis 36 

CHAPTER III. 
Atrophic Rhinitis. Membranous Rhinitis. Caseous Rhin- 
itis. Purulent Rhinitis 61 

CHAPTER IV. 
Diseases of the Accessory Sinuses. Acute and Chronic Sinu- 
sitis. Hydrops Antri, or Serous Effusion and Cyst of 
the Antrum. Foreign Bodies and Neoplasms 73 

CHAPTER V. 
Diseases and Deformities of the Nasal Septum. Deviation. 
Ecchondrosis. Exostosis. Ulceration. Perforation. 
Hematoma. Abscess. Congenital Occlusion of the Naris. 
Adhesions. Collapse of the Nostril. Dislocation of the 
Columnar Cartilage. Fracture of the Nose 114 

CHAPTER VI. 
Nasal Polypi 150 

CHAPTER VII. 
Benign Tumors and Malignant Disease of the Nasal Fossae. 

Foreign Bodies. Rhinoliths. Epistaxis 158 

CHAPTER VIII. 
Syphilis of the Nasal Foss.e. Lupus. Tuberculosis. Rhin- 

oscleroma 176 

vii 



Vlll CONTEXTS. 

CHAPTER IX. 
Nasal Neuroses. Hay Fever. Nasal Hydrorrhea 188 

CHAPTER X. 
Anatomy and Physiology of the Pharynx 199 

CHAPTER XI. 

Diseases of the Velum and Uvula. Bifid Uvula. Neoplasms 
and Malignant Disease of the Velum. Cleft Palate. 
Uvulitis and Elongated Uvula. Acute and Chronic 
Pharyngitis. Atrophic Pharyngitis. Rheumatic Phar- 
yngitis 208 

CHAPTER XII. 
Adenoids in the Rhinopharynx 222 

CHAPTER XIII. 
Hypertrophied Tonsils 240 

CHAPTER XIV. 

Diseases of the Lingual Tonsil. Abscess of the Tongue. 

Retropharyngeal Abscess. Mycosis of the Pharynx 258 

CHAPTER XV. 

Tonsillitis. Diphtheria. Circumtonsillar Abscess or Quinsy. 

Ulcero-membranous or Diphtheroid Angina 268 

CHAPTER XVI. 

Benign Neoplasms of the Tonsil. Tonsilliths. Malignant 
Disease of the Tonsils. Tuberculosis, Lupus and Syphilis 
of the Pharynx. Neuroses of the Pharynx. Foreign 
Bodies in the Pharynx 285 

CHAPTER XVII. 

Anatomy and Physiology of the Larynx. Methods of Exam- 
ination 302 



CONTENTS. IX 

CHAPTER XVIII. 
Diseases of the Larynx. Anemia and Hyperemia. Laryngeal 
Hemorrhage. Acute and Chronic Laryngitis. Chorditis 
tuberosa or vocal nodules. chronic subglottic laryn- 
GITIS. Atrophic Laryngitis 320 

CHAPTER XIX. 
Benign Neoplasms of the Larynx 333 

CHAPTER XX. 
Malignant Disease of the Larynx 350 

CHAPTER XXI. 
Tuberculosis of the Larynx 363 

CHAPTER XXII. 
Syphilis of the Larynx 382 

CHAPTER XXIII. 

Neuroses of the Larynx. Hyperesthesia. Anesthesia. Par- 
esthesia. Neuralgia. Hysterical Aphonia. Laryngeal 
Vertigo. Chorea. Spasm of the Larynx. Laryngeal 
Stridor and Whistling. Paralysis of the Larynx 391 

CHAPTER XXIV. 
Foreign Bodies in the Larynx. Prolapse of the Ventricle. 

Fracture of the Larynx 408 



LIST OF ILLUSTRATIONS. 



FIGURE. PAGE. 

i. The Nasal Septum 18 

2. Outer Wall of Nasal Fossa 19 

3. Mackenzie's Light Condenser 28 

4. Kuttner's Electric Head Light 28 

5. Head Mirror with Pomeroy Band 29 

6. Duplay's Nasal Speculum 30 

7. Hartmann's Nasal Speculum 31 

8. Jarvis' Nasal Specula 31 

9. Jarvis' Rhinometer 32 

10. Seller's Septometer 32 

11. Turck's Tongue Depressor 33 

12. Bosworth's Tongue Depressor 33 

13. White's Palate Hook 34 

14. Kyle's Postnasal Electric Lamp 34 

15. Universal Powder Blower 39 

16. Universal Vaporizer 40 

17. Lobulated Hyperplasia of Turbinates 43 

18. Cyst of Middle Turbinate Bone 44 

19. Section of Bony Cyst of Turbinate 45 

20. Lefferts' Hand Atomizer 46 

21. Woakes' Nasal Irrigator 46 

22. Nasal Syringe 46 

23. Sass' Glass Spray Tubes 47 

24. Jarvis' Cold Wire Snare 50 

25. Sajous' Snares 51 

26. Wright's Snare 52 

27. Casselberry's Nasal Scissors 53 

28. Author's Forceps and Scissors 54 

29. Schech's Cautery Handle 55 

30. Schech's Handle for Cautery Loop 55 

31. Berens' Spoke Shave 59 



Xll LIST OF ILLUSTRATIONS. 

2,2a. Lefferts' Postnasal Syringe 65 

32b. Holmes' Postnasal Douche 65 

33. Sound in Sinus Openings 75 

34. Vertical Section of Nasal Fossae yy 

35. Myles' Antrum Trocar, Canula and Washing Tube 79 

36. Lamps for Transillumination 80 

37. Myles' Antrum Drainage Tubes 84 

38. Mikulicz' Antrum Stilet 85 

39. Hartmann's Canula 85 

40. Snare Applied to Anterior End of Middle Turbinate 85 

41. Xormal Frontal Sinuses 91 

42. Asymmetry of Frontal Sinus 92 

43. Septa of Frontal and Sphenoidal Sinuses 93 

44. Incisions in Opening Frontal Sinus 96 

45. Hajek's Curette and Griinwald's Forceps 103 

46. Probe in Orifice of Sphenoidal Sinus 105 

47. Adams' Septal Forceps 118 

48. Nasal Drills, Trephines and Burrs 118 

49. Steele's Septum Punch 119 

50. Roe's Septum Forceps 120 

51. Moure's Osteotome 121 

52. Incisions in Moure's Operation 122 

53. Moure's Nasal Tube and Dilating Forceps 122 

54. Kyle's Operation for Deflected Septum 123 

55. Fetterolf's Saw File 124 

560. Krieg's Operation for Angular Deflection 126 

566. Krieg's " Window-resection " Operation 127 

57. Asch's Instruments for Deviated Septum Operation 128 

58. Nasal Tubes 130 

59. Kyle's Septum Knife 131 

600. Ecchondrosis of Septum with Furrow on Opposite Side 135 

60&. Bilateral Ecchondrosis of Septum 136 

61. Bosworth's Nasal Saws 137 

62. Dessar's Nasal Bougie 138 

62a. Nasal Polypi 155 

63. Nasal Fibroma 158 

64. Papilloma of Septum 160 



LIST OF ILLUSTRATIONS. Xlll 

65. Swollen Turbinates a Source of Epistaxis 170 

66. Hartmann-Kiesselbach Spot on Nasal Septum 171 

6y. Bellocq's Canula 172 

68. Cooper Rose's Nasal Hemostat 173 

69. Simpson's Nasal Plug 173 

70. Bishop's Nasal Bridge 178 

71. Hopkin's Nasal Bridge 178 

72. Martin's Bridge in Position 175 

73. Harmon Smith's Paraffin Syringe 181 

74. Lupus of Anterior Nares 183 

75. Tuberculosis of Turbinates 184 

76. Muscles of Soft Palate 201 

yj. Constrictors of Pharynx 203 

78. Bifid Uvula 208 

79. Chronic Follicular Pharyngitis 216 

80. Adenoids in Rhinopharynx 223 

81. Adenoids seen through Anterior Nares 228 

82. Denhard's Mouth Gag 229 

83. Schuetz' Adenotome 231 

84. Meyer's Ring Knife 233 

85. Loewenberg's Adenoid Forceps 233 

86. Brandegee's Adenoid Forceps 233 

87. Schuetz' Antero-posterior Forceps 234 

88. Motais' Artificial Finger Nail 234 

89. Gottstein's Adenoid Curettes 235 

90. Author's Adenoid Forceps 236 

91. Farlow's Tonsil Snare 245 

92. Author's Electric Tonsil Snare 246 

93. Mackenzie's Tonsillotome 249 

94. Mathieu's Tonsillotome 249 

95. Farlow's Tonsil Punch 250 

96. Butts' Tonsillar Hemostat 252 

97. Mikulicz-Stoerk Tonsil Hemostat 253 

98. Tonsil Bistoury and Knives 256 

99. Hypertrophy of Lingual Tonsil 259 

100. Roe's Lingual Tonsillotome 261 

101. Syphilitic Ulcer and Perforation of Velum 293 



XIV LIST OF ILLUSTRATIONS. 

102. Same after Complete Healing 295 

103. Multiple Perforations of Palate 296 

104. Extensive Perforation of Velum in Late Syphilis 297 

105. Muscles of Larynx, Lateral View 304 

106. Muscles of Larynx, Posterior View 305 

107. Action of Posterior Cricoarytenoid Muscles 306 

108. Action of Thyroarytenoid Muscles 307 

109. Action of Arytenoideus Muscle 308 

1 10. Nerves and Arteries of Larynx 309 

in. Superior Aperture of Larynx and Dorsum of Tongue 311 

112. Laryngeal Mirrors 315 

1 13. Escat's Tongue Depressor 316 

1 14. Papilloma of Larynx 335 

115. Fibroma of Larynx 336 

116. Cyst of Larynx 336 

117. Cyst of Epiglottis 337 

1 18. Subglottic Myxoma 338 

119. Mackenzie's Laryngeal Forceps ' 340 

120. Schroetter-Tiirck Canula Forceps 341 

121. Sarcoma of the Larynx 350 

122. Epithelioma of Vocal Band 352 

123. Advanced Cancerous Ulceration of Larynx 353 

124. Laryngeal Curettes 354 

125. Tuberculosis of Larynx 367 

126. Tubercular Ulcer of Larynx 363 

127. Tubercular Ulcer of Ventricular Band 368 

128. Tubercular Tumor of Larynx 369 

129. Tubercular Ulcer at Posterior Commissure 369 

130. Heryng's Laryngeal Curettes and Scarifiers 376 

131. Schroetter's Laryngeal Dilator 384 

132. Secondary Syphilis of Vocal Bands 385 

133. Superficial Syphilitic Lesions of Vocal Bands 387 

134. Destruction of Vocal Bands by Late Syphilis 388 

135. Hysterical Paralysis of Adductors. 392 

136. Bilateral Paralysis of Internal Thyroarytenoids 400 

137. Paralysis of Arytenoideus 400 

138. Paralysis of Internal Thyroarytenoids and Arytenoideus 401 



LIST OF ILLUSTRATIONS. XV 

139. Partial Paralysis of Right Recurrent during Respiration 402 

140. Same during Phonation 402 

141. Complete Recurrent Paralysis on Phonation 403 

142. Partial Paralysis of Posterior Cricoarytenoids 404 

143. Cusco's Laryngeal Forceps 412 



THE NOSE. 
CHAPTER I. 

ANATOMY AND PHYSIOLOGY OF THE NASAL PASSAGES. METHODS OF 
EXAMINATION. INSTRUMENTS AND APPARATUS. 

ANATOMY. 

The nasal cavities are separated by a median partition, the septum, 
composed in front of cartilage and above and behind of bone — the 
perpendicular plate of the ethmoid, or mesethmoid, and the vomer. 
The shape and dimensions of the cartilaginous septum influence 
greatly the contour of the nose and the facial expression. This car- 
tilage is quadrangular, its anterior margin forming the outline of the 
nose, and being joined in front to the lateral cartilages, which to- 
gether form the alae and tip of the nose. The nasal bones and the 
nasal processes of the superior maxillae complete the framework 
of the external nose. The septal cartilage articulates above and 
behind with the anterior margin of the perpendicular plate of the 
ethmoid, below with the vomer and the bony ridge formed by the 
junction of the palatine processes of the superior maxillse. We 
rarely, if ever, find the cartilaginous partition between the nostrils 
exactly vertical for two reasons. The prominence of the nose renders 
it particularly liable to blows and injuries, and the development of 
the cartilage frequently progresses long after the bones of the face 
have become consolidated, hence a bending or distortion of the car- 
tilage results. In consequence we meet with a great variety of de- 
formities of the cartilage which will be more fully considered else- 
where. 

The posterior portion of the septum, being composed of bone and 
occupying a more protected situation, is relatively exempt from 
violence, so that we but seldom observe any displacement or asym- 
metry of the posterior margin of the vomer, no matter what degree 
of distortion of the septal cartilage may be present (Fig. i). 

2 I 7 



DISEASES OF THE NOSE AND THROAT. 



The lateral cartilages are four in number, two on each side. Of 
these the lower have their anterior margins sharply recurved at their 
line of junction to complete the formation of the nasal septum, the 
partition between the anterior nares being called the columna nasi. 
The nasal fossse extend from the nostrils or anterior nares in front 




/ 
Fig. i. The Xasal Septum. (Deaver.) 
a, Peipendicular plate of ethmoid; b, sphenoidal sinus; c, inferior lateral car- 
tilage ; d, septal cartilage ; e, groove for naso-palatine nerve ; f, vomer. 

to the posterior nares or choanse behind and from the base of the 
skull to the hard palate. They are wider below than above and are 



ANATOMY OF THE NASAL FOSS.12. 



'9 



almost never symmetrical, owing to deformities of the septum or 
turbinate bodies. 

On the outer wall of each nasal fossa may be found the nasal pro- 
cess and the inner surface of the maxillary bone, the lachrymal, the 




Fig. 2. Outer Wall of Nasal Fossa, with Mouth, Pharynx and Larynx in 
Vertical Section. (Deaver.) 
a, Superior meatus ; b, superior turbinate body ; c, middle turbinate ; d, in- 
ferior turbinate ; e, inferior meatus ; g, tongue ; h, posterior pillar of fauces ; i, 
geniohyoglossus muscle ; /, geniohyoid muscle ; k, hyoid bone ; /, mylohyoid 
muscle ; m, thyrohyoid membrane ; n, ventricle of larynx ; o, thyroid cartilage ; 
p, diaphragma sellae ; q, cavum sella; ; r, sphenoidal sinus ; s, middle meatus ; 
t, rhinopharynx ; u, eustachian orifice ; v, hard palate ; zv, soft palate ; x, uvula ; 
y, anterior pillar of fauces ; z, tonsillar fossa ; aa, oropharynx ; bb, epiglottis ;: 
cc, arycpiglottic fold ; dd, laryngopharynx ; ee, suprarimal portion of larynx ; 
//, ventricular band; gg, vocal band; hh, infrarimal portion of larynx; ii, cricoid 
cartilage ; //, tracheal ring. 



20 DISEASES OF THE NOSE AND THROAT. 

ethmoid, the palate, the inferior turbinate bones, and the internal 
pterygoid plate of the sphenoid. The roof of the fossa is bounded 
by the nasal bone, the nasal spine of the frontal, the cribriform plate 
of the ethmoid and the body of the sphenoid. The floor of the naris 
is formed by the horizontal plates of the superior maxillary and 
palate bones. Each nasal cavity is partially subdivided by horizontal 
projections from its outer wall, the turbinate bones, which vary in 
size and number in different individuals, and which with the soft 
tissues covering them constitute the turbinate bodies. They are fre- 
quently described as being " scroll-shaped." In other words, in the 
normal condition, their septal surface is convex and their under and 
outer surface is concave (Fig. 2). 

Of these, the inferior is the only independent bone. The middle 
and superior are really processes of the ethmoid, as is likewise the 
fourth turbinate, or concha suprema, which is said to exist in about 
one in three or four specimens. The superior turbinate is practically 
a subdivision of the middle, with which it merges anteriorly. The 
turbinate bodies are of great interest and importance from a patho- 
logical as well as a physiological standpoint, not only in themselves 
but from the relation they bear to adjacent parts. 

The inferior meatus is that portion of the nasal passages lying 
beneath the inferior turbinate body and has opening into it the nasal 
duct which conveys secretion from the lachrymal sac. The duct 
itself is half to three quarters of an inch long and runs downwards, 
backwards and outwards. Its nasal orifice, near the anterior end 
of the turbinate body, is protected by a fold of mucous membrane 
called the valve of Hasner. This membranous valve ordinarily 
prevents distention of the lachrymal sac, as by air in the act of blow- 
ing the nose, but recent observations have shown that fluids may 
pass through it from the nasal cavity. Several other valvular folds 
of mucous membrane in the course of the duct have been described 
by recent anatomists. 

Above the inferior turbinate and below the middle lies the region 
known as the middle meatus, into which open the passages from 
the antrum of Highmore, the frontal sinus, and the anterior ethmoidal 
cells. The most anterior is that qf the frontal sinus, near the superior 
extremity of a crescentic furrow in the wall of the meatus known as 



ANATOMY OF THE NASAL FOSSAE. 2 1 

the hiatus semilunaris, and usually just behind it is that of the eth- 
moidal cells. This part of the meatus including the orifices of the eth- 
moidal cells and of the frontal sinus is called the infundibulum. 
Sometimes the antrum, or maxillary sinus, has two openings. 

The hiatus semilunaris runs obliquely downwards and backwards 
from near the anterior end of the middle turbinate, and lies below 
the bulla ethmoidalis, an expanded ethmoid cell which projects into 
the meatus. The unciform process of the ethmoid, a thin plate of 
bone which articulates with the superior maxilla and with the in- 
ferior turbinate, and which enters into the formation of the nasal 
wall of the antrum, forms the lower boundary of the hiatus semi- 
lunaris. The ostium maxillare, the larger and more constant orifice 
of the antrum, is situated at about the middle of the hiatus. 

The space above the middle turbinate is called the superior meatus, 
into which open the posterior ethmoidal cells and the sphenoidal 
sinus. The orifice of the spheno-palatine foramen, covered by 
mucous membrane, is just above the posterior end of the middle 
turbinate body. At the line of articulation of the ethmoid with the 
nasal process of the superior maxilla near the anterior end of the 
middle turbinate, appears a prominence on the outer wall of the 
fossa which has been described as the agger nasi. That portion of 
the fossa included by cartilage is called the vestibule of the naris, 
and is the only dilatable part of the passage, a point to be remem- 
bered in using the nasal speculum. The mobility of the alas of the 
nose, which is very highly developed in some of the lower animals, 
is provided for by the insertion of a number of sesamoid and acces- 
sory cartilages between the lateral cartilages and the nasal processes 
of the superior maxillae. To these, as well as to the cellular tissue at 
the margin of the nostril, muscular fibers are attached. 

Two other points of interest in the septum should be referred to, 
the organ of Jacobson, which exists in man in the form of a cul-de- 
sac just within the nostril and above the floor of the nose, and the 
tubercle of Morgagni, or Zuckerkandl, a spindle-shaped aggregation 
of glandular tissue over the vomer opposite the anterior end of the 
middle turbinate body, at the line of junction of the cartilage and 
the perpendicular plate. It has recently been suggested that the 
former may bear an important relation to perforations of the septal 



22 DISEASES OF THE XOSE AND THROAT. 

cartilage, which are frequently met with quite independently of 
syphilis, or other constitutional taint, while the latter when present 
in unusual volume may readily be mistaken for a pathological con- 
dition. 

The floor of the nasal cavity is not flat, but slopes slightly down- 
wards and backwards and is concave from side to side. The crest 
of the maxilla forms a considerable eminence just within the nostril, 
and behind it close to the septum is a shallow cul-de-sac indicating 
the situation of the duct of Stenson, which is marked in the mouth 
by the incisive papilla. The position of the anterior palatine canal, 
of which the duct is a subdivision, is important. Here the artery 
of the septum from the sphenopalatine, the terminal branch of the 
internal maxillary, anastomoses with the anterior palatine artery 
from the descending palatine. Erosion or rupture of this arterial 
twig at the angle formed by the septum and the floor of the nose is 
a frequent source of epistaxis. 

The pituitary membrane lining the nasal cavities, known as the 
Schneiderian membrane, is continuous with that of the accessory 
sinuses, with that of the orbits through the nasal ducts, and with 
that of the tympana through the Eustachian tubes. It is much 
thicker and more vascular over the lower part of the septum and the 
turbinate bones, especially the inferior, than elsewhere. The transi- 
tion from integument to mucous membrane is very gradual. In the 
vestibule the mucous lining shows numerous vascular papillae and is 
covered with squamous epithelium. Just at the nostril are a number 
of short hairs or Tibrisscc which are intended to filter the inspired 
air. The epithelium of what is generally considered the respiratory 
region of the nose, or that part below the plane of the middle turbi- 
nate body, is columnar ciliated. The columnar epithelium lining 
the olfactory tract is not ciliated. The muciparous glands are tubular 
and of unusual length, extending through the entire thickness of 
membrane. In the olfactory region, besides the muciparous glands, 
we find tubular glands lined with round epithelium containing pig- 
ment, called Bowman's glands. 

The direction of the inspiratory current is influenced by the shape 
and position of the nostrils and by the vigor of the act of breathing. 
Recent experiments indicate that even in quiet inspiration the air 



ANATOMY OF THE NASAL FOSSAE. 23 

current does not pass directly backwards along the floor of the 
nose, but describes an upward curve and passes more or less over 
the middle turbinate body. In expiration it is supposed to be de- 
flected abruptly from the vault of the pharynx and pass out at a 
lower level. 

The nerve of special sense of smell, the olfactory nerve, reaches 
the upper part of the nasal cavity through perforations in the cribri- 
form plate of the ethmoid. It is distributed to the roof of the nose, 
to the superior and middle turbinate bodies and to the opposite sur- 
face of the septum. The terminal filaments of this nerve, just before 
reaching the surface of the mucous membrane between the epithelial 
cells, present fusiform expansions called the olfactory cells of 
Schultze. The subdivisions of the olfactory nerve, upwards of 
twenty in number on each side, are invested with a coat from the dura 
mater and are said to differ from other cranial nerves in containing 
no white substance of Schwann and in having axis-cylinders with a 
distinct nucleated sheath which presents few and separated nuclei. 

The sensory nerves of the mucous membrane are derived from the 
fifth pair. Filaments from the external division of the nasal branch 
of the ophthalmic and from the Vidian supply the roof. The outer 
wall receives filaments from the superior nasal branches of the 
spheno-palatine ganglion, from the nasal, from the inner branch of 
the anterior dental and from the inferior nasal branches of the large 
palatine nerve. The septal branch of the nasal nerve, nasal branches 
of the spheno-palatine ganglion, the.naso-palatine, and the Vidian 
are distributed to the septum. The floor is supplied by the naso- 
palatine and the inferior nasal branches of the large palatine nerve. 

The arteries of the nasal cavities are derived from the anterior 
and posterior ethmoidal branches of the ophthalmic, which supply the 
roof of the nose, the anterior and posterior ethmoidal cells and the 
frontal sinuses ; from the nasal artery of the internal maxillary, 
which supplies the septum, the meatuses, and the turbinate bodies ; 
from the posterior dental branch of the internal maxillary, which 
supplies the antrum (Holdcn). The veins, which accompany the 
arteries, communicate with the intracranial veins through the fora- 
mina in the cribriform plate, as well as through the ophthalmic vein 
and the cavernous sinus. 



24 DISEASES OF THE NOSE AXD THROAT. 

The mucous membrane covering the turbinate bones has a peculiar 
structure demanding special description. Its sponge character has 
long been recognized and fifty years ago Cruveilhier defined it as 
true erectile tissue. Later Kohlrausch. Bigelow and others made 
careful anatomical studies of this tissue, and still more recently the 
exhaustive investigation of Zuckerkandl established the existence of 
so-called "turbinated corpora cavernosa." It seems that the deep 
layer of the mucous membrane forms the periosteum. Distributed 
freely through the connective tissue of the membrane are lymph 
issue and tubular mucous glands of extraordinary length. Within 
the lymphoid tissue are numerous venous sinuses 'surrounded by an 
abundance of unstriped muscular fiber. The " erectile tissue " 'thus 
constituted ,s subject to rapid and extreme variations in its dimen- 
sions under the influence of atmospheric conditions and of mechanical 
natation, as well as of mental emotions. In dry air, these bodies 
retract, m a humid air they swell. When this process of ^ 
and expansion has been too frequently repeated a condition of vaso- 
motor paresis becomes established, which results in more or less 
permanent enlargement of the turbinate body, with consequent nasal 
= s. p| Ih,s is the flrst stage of what will later 1, dLri^d as 

The accessory sinuses, which are supposed to contribute to the re- 
sonance of the voice, to diminish the weight of the skull and to 
afford pretectal to the nerve centers, are four in number on either 
side, the maxillary sinus, or antrum of Highmore, the frontal sinus, 
the ethmoidal sinuses, usually called cells, and the sphenoidal sinus. 
Of these, the largest is the maxillary sinus, which is a cavity in the 
superior maxilla bounded above by the floor of the orbit, within by 
the outer wall of the nasal fossa, and below by the roof of the 
mouth, its floor therefore being considerably below its normal outlet 
which is found in the middle meatus. The frontal sinus lies between 
the tables of the frontal bone, the roof of the orbit forming its 
floor A more or less complete median partition usually separates 
the frontal sinus into two parts. I, also opens into the middle meatus 
near the orifice of the anterior ethmoidal cells. The sphenoidal sin- 
uses are two excavations in the body of the sphenoid bone sometimes 
divided by a vertical septum, but frequently communicating so as to 



PHYSIOLOGY OF THE NOSE. 25 

form a single cavity. The ethmoidal cells, as their name denotes, 
are multiple cavities in the body of the ethmoid, separated by thin 
bony plates and arranged in two groups, anterior and posterior, the 
former opening into the middle, the latter into the superior meatus. 
The nasal orifices of the maxillary and frontal sinuses, and of the 
anterior ethmoidal cells, are in close proximity, and it has been 
shown that secretions from the frontal sinus may drain into the 
antrum and give many of the symptoms of antral disease. The 
clinical importance of this fact is very great, since opening the 
maxillary sinus under such circumstances would of course be en- 
tirely futile. Not infrequently the posterior ethmoidal cells open 
into the sphenoidal sinus. The anatomical relations of the accessory 
cavities and the variations from their normal arrangement are thus 
seen to be sources of difficulty in positively identifying sinus disease. 



PHYSIOLOGY. 

The nose is the organ of the special sense of smell, but its more 
important duties relate to the act of respiration, it being so con- 
structed as to warm, moisten and filter the inspired air. We may 
remain in comparative comfort without the ability to detect odors-, 
but complete, or even partial, stenosis of the nostrils is a serious 
impediment to health. It is merely necessary to cite the familiar 
example of an individual with " a cold in the head " to indicate the 
importance of unobstructed nasal passages to the production of a 
clear and resonant voice. Olfaction, respiration and phonation are 
therefore all more or less affected by morbid conditions in the nasal 
chambers. 

The sense of smell resides in the upper part of the nasal cavity, 
the olfactory nerve being distributed as low down as the middle of 
the middle turbinate body and the opposite surface of the septum. 
It is essential that odoriferous particles should reach this region, 
that the mucous membrane should be healthy, and that the nerve 
supply should be unimpaired. Otherwise the sense of smell may be 
lost, a condition known as anosmia. An interesting perversion of 
the sense of smell, the subjects of which perceive an odor not pres- 
ent, is called parosmia, and is undoubtedly a neurosis. It is some- 



26 DISEASES OF THE NOSE AND THROAT. 

times regarded as a precursor of mental alienation. Precisely how 
odors are appreciated is a matter of pure theory. Mechanical irrita- 
tion of the nerve filaments in the pituitary membrane, oxidation of 
odoriferous particles, molecular vibration, the heat-absorbing power 
of different materials, and finally the pigment-secreting quality of 
Bowman's glands have all been suggested in explanation of the 
function. The important degree to which the sense of smell con- 
tributes to our pleasure may be realized when we recall the limita- 
tions of the sense of taste, all flavors, with the exception of acid, 
bitter, sweet and salt, being recognized only through the olfactory 
nerve. The keenness of this sense depends in part upon the extent 
of the olfactory membrane. For this reason, the turbinate bodies in 
some of the lower animals are extraordinary in shape and dimen- 
sions. It is also said that its acuteness may be developed by prac- 
tice. 

A theory of the sense of smell recently propounded maintains 
that it is not due to contact of odoriferous particles with the nasal 
membranes, but to rays analogous to those of light, heat and the 
Roentgen-ray (Yaschide and v. Melle). The following reasons are 
given for adopting this hypothesis : 

i. Sensations are excited by the surrounding media rather than 
directly by substances. 

2. The origin and, probably, the mode of action of the olfactory 
nerve are similar to those of the optic. 

3. The spectra of chemical odoriferous substances of the same 
group resemble each other. 

4. Odors absorb radiant heat. 

5. Some bodies giving off particles have no smell, while others 
with strong smell give off no particles. 

6. Certain bodies neutralize each other's odor. 

7. The absorbing power of fabrics varies with their color. 

8. The capacity to recognize one odor may be lost while being 
retained for all others ; an olfactory fatigue similar to that affecting 
the eye for colors. 

9. Fluid, as well as air, is a vehicle for odors since the sense of 
smell is found to be active when the nostrils are flooded with an 
odoriferous fluid. 



PHYSIOLOGY OF THE NOSE. 2J 

The inhalation of air at an unsuitable temperature, of an excessive 
degree of dryness, or laden with impurities is a source of irritation 
to the lower air passages and sooner or later of disease. Numerous 
experiments have been made in order to determine the increase in tem- 
perature and saturation which the inspired air undergoes in its 
transit through the nasal passages. It has been demonstrated that 
by the time the air reaches the pharynx through a normal nose, 
whatever the degree of external cold, it has become almost or quite 
as warm as the blood, and at the same time has become saturated 
with moisture, however dry the atmosphere may be. The interest- 
ing fact has also been established that the nose supplies to the ex- 
pired air a small proportion of carbonic acid, estimated at about one 
fiftieth part of that contributed by the lungs. An examination of 
an individual exposed to a dust-laden atmosphere is sufficient to 
satisfy one of the extent to which foreign bodies in the inspiratory 
current are detained in the nasal fossae. In view of its complex 
functions it is easy to understand the importance of a normal nose, 
not necessarily a nose with perfectly symmetrical turbinate bodies, 
or with a septum absolutely smooth and vertical, but one capable of 
conveying to the lungs an adequate supply of pure air of proper 
quality. 

The resonance and timbre of the voice are markedly influenced 
by the shape and size of the nasal cavities, and an agreeable quality 
is given it by the formation within the nasal chambers of those 
secondary vibrations to which has been given the name, " over- 
tones." 

An attempt has been made to draw conclusions as to the site of 
intra-nasal lesions from the varying impressions they produce upon 
the quality of the voice, but we find it impossible to go farther than 
to say that stenosis of the anterior nares merely diminishes the re- 
sonance of nasal sounds, which is retained in a measure so long as 
the naso-pharynx remains normal. The so-called " dead voice " of 
the condition known as adenoids in the vault of the pharynx is an 
example of absolute loss of resonance. 



28 



DISEASES OF THE NOSE AND THROAT. 



EXAMINATION AND INSTRUMENTS. 

The first essential to satisfactory examination of the upper air- 
passages is a good light. Sunlight may be utilized by means of a 
system of mirrors, but is not always to be had, and for the sake of 
convenience we resort to artificial sources of illumination. A Ger- 
man student oil lamp, fitted with a Mackenzie condenser (Fig. 3), will 
answer the purpose, but the Argand gas burner is better. Many 
attempts have been made to bring the electric light to our service and 
various head lights (Fig. 4) and lamps for use within the condenser 
have been devised, but, thus far, they have not been brought to per- 
fection. The best light proposed, up to the present time, is what is 




Fig. 3. Mackenzie's 
Light Condenser. 



Head Light. 



known as the improved Welsbach light, which consists of a gauze 
network, chemically prepared, and placed over the Argand flame. 
This network, or mantle, is rather delicate and must be handled 
carefully, but when protected by a mica chimney and the bullseye 
condenser, will burn upwards of 1,000 hours and gives a very beauti- 
ful white light. It is so brilliant that many prefer to use it without 
the bullseye. It is as intense as the electric light, is perfectly steady, 
and, what is by no means its least advantage, it radiates but little 
heat as compared with the ordinary gas jet. It is also said to con- 
sume a relatively small proportion of gas. The mantle may be re- 
newed at trifling cost, and the original outfit is inexpensive. Having 
secured a good light we next seek to reflect it upon the parts to be 



METHODS OF EXAMINATION. 



2 9 



examined. In the more elaborate apparatus, as Tobold's, the re- 
flector is attached to the lamp. It will be found more convenient, 
however, to wear the reflector upon the forehead. A concave glass 
mirror, 3^/2 inches in diameter, with a focal distance of about 16 
inches and framed in aluminum may be attached to a Pomeroy fore- 
head piece and held to the head by means of a band of leather or silk 
braid, an inch in width (Fig. 5). It is very light, and may be worn 
indefinitely with comfort, and is to be preferred for operative work 
and when one has a large number of patients to examine successively. 






IllSt 





Fig. 5. Head M 



th Pomeroy Band. 



In all examinations of the nose and throat let the source of light 
be on the right of the patient, so that the right hand of the examiner, 
with which most of the manipulating is usually done, may not inter- 
fere. The examiner should sit facing his patient with his knees 
separated, one on either side of the patient's knees. The position 
advocated by some, with the knees of the examiner together and on 
one or the other side of the patient, may be a gain in elegance, but 
is a sacrifice of steadiness, a point of importance in operating. The 



30 DISEASES OF THE NOSE AND THROAT. 

head mirror should be worn over the left eye in such a way that both 
eyes may be brought into service. After a little experience one 
knows instantly whether binocular vision is obtained. At first an easy 
way to settle the question is to close the right eye and if then the 
open left eye looking through the aperture in the center of the head 
mirror includes the whole circle of light thrown at the focal distance 
by the reflector, one may be sure of using both eyes. On very close 
inspection of points in the depths of the nasal fossae only one eye at 
a time can be used. It is well to have all the instruments to be 
brought in contact with the patient comfortably warmed. In the 
case of throat mirrors this is indispensable in order to obviate con- 
densation of moisture upon the glass. The mirror should be warmed 
by holding it face down, over the gas flame for a few seconds, and 
the degree of heat should be tested on the ball of the examiner's 
thumb before the mirror is placed in the throat. Nothing so unnerves 
a timorous patient, aside from general awkward management, as the 
touch of an excessively hot mirror. 

Inspection of the nasal and naso-pharyngeal cavities is called 




Fig. 6. Duplay's Nasal Speculum. 

rhinoscopy. By anterior rhinoscopy we discover the condition of 
the cartilaginous septum and of the anterior ends of the middle and 
inferior turbinate bodies. This procedure is very much facilitated 
by preliminary spraying of the nares with a four per cent, solution of 
cocaine. The indiscriminate use of cocaine, however, should not be 
encouraged, and it never should be used until we have first seen the 
parts in their natural state. We study the posterior nares and the 
naso-pharynx by means of small mirrors introduced into the oro- 
pharynx, or posterior rhinoscopy. 

A good nasal speculum in anterior rhinoscopy is almost as neces- 
sary as good illumination. The ideal speculum should be easy of 



METHODS OF EXAMINATION. 3 I 

manipulation, should give the patient no discomfort, and should be 
capable of admitting a generous flood of light. Such an one we 
have in the Duplay speculum (Fig. 6). Its solid blades have the 
double advantage of exerting uniform diffuse pressure and at the 
same time push aside the vibrissa?, which grow so profusely in 




Fig. 7. Hartmann's Nasal Speculum. 

the nostrils of some patients, and which are apt to protrude through 
the opening of a fenestrated speculum and impede the rays of light. 
Hartmann's speculum is also a very convenient instrument (Fig. 7). 
It should be remembered that the walls of the nasal vestibule are but 




Fig. 8. Jarvis' Nasal Specula. 
slightly dilatable, hence the importance of using a speculum the 
separation of whose blades may be regulated at will. All fenestrated 
instruments, with uncontrolled springs, are to be condemned. In 



32 



DISEASES OF THE NCSE AND THROAT. 



operating far back in the nasal cavity the Jarvis speculum (Fig. 8). 
is found to be more convenient, since it is lighter and more properly 
self-retaining, and is less apt to get in the way of the operator. 

No rhinoscopic examination should be considered complete until 
inspection of the mucous membrane has been supplemented by pal- 
pation with the probe. We thus gain information as to the 
vascularitv, the density and the mobility of the structures normal or 




Fig. 9. Jarvis' Rhinometer. 

morbid. It is also frequently important to determine the sensitive- 
ness of the pituitary membrane, or to define areas of suspected hyper- 
esthesia. If still more exactness is desired we may measure the width 
of the nasal passages at various points by means of Jarvis' rhinom- 
eter. or the thickness of the septum with Seder's septometer (Figs. 
9 and 10). 

In posterior rhinoscopy we frequently have to contend with various 
obstacles, such as a rebellious tongue which resents the pressure of 




Seiler's Septometer. 



the tongue spatula, an irritable pharynx whose muscles contract in 
the act of gagging almost as soon as the mouth is widely opened, an 
unusually narrow space between the palate and the pharyngeal wall, 
or persistent elevation of the velum during our attempt to illuminate 
the posterior nares. In many cases we succeed in getting a view 
only by the exercise of the utmost tact and patience, and our subject 
may have to be put through a course of training for several weeks 



METHODS OF EXAMINATION. 



33 



before we succeed in getting more than a glimpse of the parts we 
wish to explore. The tongue should never be roughly handled. A 
Tiirck depressor with a smooth tongue piece, held in the examiner's 
left hand, should be applied to the middle of the dorsum of the 
tongue not too far back and steady, firm pressure made in a down- 
ward direction (Figs, n and 12). The rhinoscopic mirror, No. 1, 
or larger in trained subjects, properly warmed, is then introduced 
face upwards to the right of and behind the uvula, care being taken 
to avoid sudden and rough contact with the wall of the pharynx. 





Turck's Tongue De- 
pressor. 



Bosworth's Tongue 
Depressor. 



The patient is directed to breathe quietly meanwhile through the 
nose. By gently raising or lowering the right hand which holds the 
mirror and by slightly rotating the shaft without shifting the mirror 
about in the fauces, the examiner will finally get all the details of the 
rhinoscopic image. It is rarely possible to use a mirror large enough 
to give a complete picture. 

Irritability of the pharynx may usually be overcome by frequent 
repetitions of examination from day to day. Attempts at the first 
3 



34 DISEASES OF THE NOSE AND THROAT. 

sitting should be abandoned in case there is found to be extreme 
sensitiveness. We may sometimes succeed in establishing tolerance 
by directing the patient to pass his forefinger far back upon the 
dorsum of the tongue and over the velum several times a day, thus 
accustoming the pharynx to the presence of a foreign body. The 
patient may hold small pieces of ice in the mouth for fifteen minutes 
before examination, or if the necessity is urgent, we may spray the 




Fig. 13. White's Palate Hook. 

pharynx with a four per cent, cocaine solution. Cocaine may defeat 
us by the nausea which it excites in certain individuals. It should 
be used for purposes of examination only as a last resort, and the 
patient should always be warned of the discomfort it is likely to 
cause. In some cases assistance may be gained from the use of a 
palate hook by which the velum is held forward. One of the most 
convenient is White's (Fig. 13), which has been modified by dis- 
pensing with the joint in the shaft and adjusting a rubber band, so 
as to make the instrument automatic. For ordinary use it is not to 




Fig. 14. Kvi.f.'s Postnasal Electric Lamp. 

be recommended, since we find that it is most easily applied in those 
tolerant throats which permit a satisfactory examination without it. 
Yet in certain rare cases of doubtful diagnosis, or in which the elec- 
tric cautery is to be used in the naso-pharynx, it will be found ser- 
viceable. After an application of cocaine it is sometimes borne with- 
out objection. 

A thickened or elongated uvula, or hypertrophied palatal tonsils 
may add more or less to the difficulties of a posterior rhinoscopy, but 
thev are seldom insurmountable. 



METHODS OF EXAMINATION. 35 

A small electric lamp fixed at a right angle and attached to a suit- 
able handle and battery may be passed behind the velum, and gives 
an excellent illumination of the pharynx as well as of the nasal cavi- 
ties. After the patient has learned to keep the lamp in place with the 
closed lips a good view may be obtained by looking through the 
anterior nares. Such a lamp as that devised by Kyle (Fig. 14), 
which is protected by a movable aluminum cap, produces little or no 
discomfort by the evolution of heat. 

Digital examination of the naso-pharynx is a procedure too much 
neglected. It is by no means agreeable to the patient, but it may be 
done quickly, and it is well for the student to familiarize himself 
with the landmarks of this region by the sense of touch. In young 
children, and in those who will not tolerate rhinoscopy, it is the only 
way by which a knowledge of the extent and disposition of lymphoid 
hypertrophies may be gained. In practising this method in young 
subjects the finger may be protected by a jointed metal shield, or this 
may be dispensed with by adopting the following course. The child 
is held in the lap of the mother, or of an assistant, who controls its 
hands. The examiner then standing on the child's left presses his 
right middle finger firmly upon the patient's right cheek, at the same 
time bringing its head against his own body. The firm pressure 
causes the child to open its mouth, when at once the examiner's 
left forefinger should be passed into the pharynx. The pressure 
being maintained the cheek is pushed between the teeth of the open 
mouth, and the examining finger is pretty safe from harm, since the 
child cannot close its jaws without biting its own cheek. The ex- 
amining finger may be protected by passing over it a piece of elastic 
rubber tubing, which interferes but little with the movements of the 
finger and the delicacy of touch. 



CHAPTER II. 



ACUTE AND CHRONIC RHINITIS. 



Inflammation of the mucous membrane lining the nasal passages, 
or rhinitis, may be acute or chronic. The phenomena of chronic 
rhinitis are so complex and its complications and consequences so 
varied as to demand extended description. 

The symptoms of acute rhinitis, or coryza, are familiar and need 
but little attention. The majority of people have a " cold in the 
head " from time to time, think it of slight consequence and let it 
run its course. It is certainly worth while, however, to consider the 
causes of " catching cold " and the measures adapted to its preven- 
tion and relief. In addition to individual proclivity based upon a 
diathetic condition, there may be certain local structural changes and 
relations within the nasal fossa? which make one particularly liable 
to catch cold. Moreover, we all recognize the fact that certain occu- 
pations which involve exposure to frequent and abrupt changes of 
temperature or to irritating vapors, increase the liability. The nerve 
theory of etiology is maintained by some. A neurotic element is no 
doubt often prominent and the predisposing influence of depressed 
general health is beyond question. It is undeniable that a general 
atmospheric state sometimes exists which leads to the development 
of a pandemic of acute rhinitis. As yet we have no positive proof 
that rhinitis may be transmitted by contagion. Some of the causes 
immediate and remote are avoidable, and it is equally true that the 
course of the disease may be cut short by appropriate treatment. 
Many of the more serious and distressing chronic affections of the 
nose have their origin in a neglected cold in the head. 

Prophylaxis is a far more important function of the physician than 
drug giving. The question of ventilation, especially of sleeping 
rooms, and the matter of quality and kind of underclothing are sub- 
jects by no means beneath his notice. They certainly have a most 
serious bearing upon the susceptibility of a patient to cold from ex- 
posure. We all know the danger of sudden chilling of the surface 

36 



ACUTE RHINITIS. 2)7 

when overheated. We think less of the ill effects of superheated 
foul air in our homes and places of amusement. The use of cold 
water as a means of toughening the cutaneous surface is highly esti- 
mated and perhaps justly, but many of its enthusiastic advocates lose 
sight of the depressing effect it may have upon the general system. 
By judicious hints as to points of hygiene, dress and diet, it is doubt- 
less possible to prevent many of the catarrhal affections which are so 
difficult to cure. How far climatic influences are factors in the causa- 
tion of " catarrh " it is difficult to say. A similar observation is 
true of the tobacco and alcohol habits. It is not unusual to hear a 
patient say that he never has trouble except when he comes to New 
York, while the next visitor may remark that he is never so com- 
fortable elsewhere. One patient will affirm that tobacco and alcohol 
invariably aggravate his catarrhal symptoms, while the next, an in- 
veterate smoker, will express his belief that tobacco has preserved his 
health. It seems to be impossible to lay down an arbitrary rule on 
these points. They are matters of individual experience. In general 
terms it may be said that the excessive use of these luxuries is harm- 
ful. What constitutes excess depends upon the temperament, the 
occupation and the general habits of life. Moderation in one may be 
excess in another. The relationship between sexual excitement and 
turgescence of the nasal erectile tissue is obvious and sexual excess 
must be included among the factors in the etiology of rhinitis. 

As to the propriety of the term "catarrhal diathesis," which is 
sometimes used to indicate a propensity to inflammation on the part 
of the mucous surfaces generally, it is reasonable to assume the ex- 
istence of a constitutional condition which influences the vital resist- 
ance and functional activity of the mucous membranes as well as of 
other tissues and organs of the body. 

In the first stage of an acute rhinitis, the mucous membrane is 
abnormally dry and the patient is conscious of some obstruction to 
nasal breathing. Sneezing, lachrymation, more or less frontal heavi- 
ness, or actual headache, with a feeling of general lassitude and de- 
pression, comprise the usual train of symptoms. If the inflammatory 
process actually extends to one or more of the accessory sinuses, 
which, fortunately, rarely happens, there is more decided pain, neural- 
gic in character. There is generally more or less congestion of the 



38 DISEASES OF THE NOSE AND THROAT. 

sinuses associated with an acute rhinitis, and especially in the frontal 
region there may be complaint of sensitiveness and a feeling of ten- 
sion. The sense of smell may be completely abolished for the time 
being. One of the most annoying symptoms is the tinnitus aitrium, 
frequently accompanied by impairment of hearing and a sense of 
fulness in the ears, dependent, no doubt, upon extension of the in- 
flammatory process to the naso-pharynx and the orifices of the Eus- 
tachian tubes. There may be a mild degree of pyrexia. In the course 
of a few hours the dryness of the membranes is succeeded by an 
effusion of watery secretion, more or less profuse, at first mucous 
and gradually becoming purulent. In the declining stage the dis- 
charges become thicker and dryer. If inspected in the prodromic 
stage the mucous membrane will be seen to be excessively tumefied, 
dry and glazed, and very red. In the second stage the swelling and 
redness may persist, but the surfaces are bathed in mucus. In the 
final stage we find the congestion and swelling less, but the nasal pas- 
ages are apt to be obstructed by tenacious purulent and inspissated 
secretion. Usually in a week or ten days the patient is restored to 
health, but not without perceptible aggravation of a preexisting 
abnormality, or certain changes in the tissues which increase the 
tendency to recurrent attacks. 

Treatment. — An attack of acute rhinitis may be invariably miti- 
gated and sometimes aborted. At the outset ten grains of quinine 
with ten grains of Dover's powder should be given to an adult, and 
proportionate doses to children, unless there is some known contra- 
indication. Measures tending to encourage perspiration are often 
used with benefit, such as the hot foot bath and hot lemonade in- 
ternally. Some observers insist upon entire abstention from fluids 
internally, with the result, it would seem, of adding rather to the 
patient's discomfort. On the other hand Cohen recommends copious 
draughts of water. The less local meddling the better, but there 
seems to be no doubt that an application of cocaine, two per cent, 
to the inflamed nares, followed by an insufflation of Ferrier's snuff 
(morph. sulph. gr. i, bismuth, subnitr. oiii, pulv. acacia oi) is very 
soothing and will contribute to the comfort of the patient (Fig. 15). 
Cocaine should never be entrusted to a patient except in extreme 
cases and unless we are quite sure of his capacitv to resist the fasci- 



ACUTE RHINITIS. 



39 



nations of the habit. The question of the local effect, damaging or 
Otherwise, of repeated and prolonged use of cocaine is still undeter- 
mined. The abuse of an agent, so energetic and decided in its action, 
may do permanent harm. There is no doubt about the comfort it 
gives by emptying the venous sinuses and thus restoring the caliber 
of the nostrils. But its effects are transitory, and the temptation to 
resort to it again and again is almost irresistible. The promiscuous 
recommendation of cocaine is, therefore, dangerous and should be 
discountenanced. A solution of cocaine alkaloid, two per cent, in 




equal parts of almond and petroleum oil has been found by Wyatt 
Wingrave to give more prolonged results though acting somewhat 
more slowly than a watery solution. A five per cent, watery solution 
of cocaine hydrochloratc, containing two per cent, sodium sulphate, 
proved to give as complete effects as much stronger solutions of 
cocaine alone. Thus the danger of toxic symptoms is much reduced 
and moreover the combination is more rapid in its action. The 
inhalation of a vapor of camphor and menthol (5 grs. of each to one 
ounce of fluid albolene or benzoinated albolene) will usually give 
temporary relief and may be safely repeated at short intervals. The 



40 DISEASES OF THE NOSE AND THROAT. 

patient may be instructed to inhale from a wide-mouthed bottle con- 
taining equal parts of powdered camphor and menthol to which a few 
drops of ammonia have been added. The famous Hager-Brand 
remedy (acid, carbol. 5i, alcohol oiii, aq. amnion, fort, oi, aq. distill, 
oii) may be used in a similar way, or may be sprinkled on a hand- 
kerchief and inhaled. Many drugs of this class may be satisfactorily 
inhaled from a nebulizer or vaporizer (Fig. 16). 

A combination, the value of which has been somewhat exagger- 
ated, for controlling secretion and reducing the turgescence of the 
erectile tissue, is a tablet (rhinitis tablet) containing one eighth of 




Fig. 16. Universal Vaporizer. 

a minim of belladonna fl. ext. and one fourth grain each of camphor 
and quin. sulph. to be given half hourly until ten or twelve have been 
taken or the patient becomes aware of a feeling of dryness in the 
pharynx. In malarial cases quinine is indicated. In rheumatic and 
gouty subjects the salicylates and antilithics are of service. In this 
connection it is of interest to note the alkaline treatment of a " cold 
in the head," as advocated by Bulkley, who gives bicarbonate of soda 
in full and frequent doses. The necessity of treating a rhinitis com- 
plicating the exanthemata in children by means of cleansing and 
germicidal solutions should be appreciated. The relative importance 
of general symptoms sometimes leads to neglect of the local condi- 
tions with disastrous results. Space does not permit a reference to 
numerous other remedies, local and general, most of them of indiffer- 
ent value, with the exception of adrenal extract, to be referred to 



CHRONIC RHINITIS. 4 I 

in detail in the section on hay fever, and to the use of hourly 
insufflations of orthoform, either pure or combined with sodium 
sozoiodolate, as confidently recommended by Spiess. Its use is based 
on the neuropathic theory of causation, and the applications are said 
to be more effective if made through the mouth to the vault of the 
pharynx, the intention being to reduce reflex irritability. In con- 
junction with the local treatment various drugs classed as antineural- 
gics or nervines are given internally. 

In a small proportion of cases convalescence from a course of acute 
rhinitis does not ensue and we have established a condition of chronic 
rhinitis, known to the public and to many general practitioners as 
" catarrh." 

For the sake of simplicity, we may divide chronic rhinitis into three 
varieties, catarrhal, hypertrophic and atrophic, basing this subdivis- 
ion upon the clinical phenomena characteristic of each. Several other 
forms, comparatively rare and named from certain prominent symp- 
toms, will be described. 

In chronic catarrhal rhinitis hypersecretion is the principal symp- 
tom. The patient soils many handkerchiefs during the day and is 
constantly annoyed by the accumulation of secretion in the post-nasal 
space. Nasal respiration is not perceptibly impeded, or the patient 
may complain of intermittent stenosis alternating between the nos- 
trils. We have here then an early sequel of an acute process which 
involves mainly the glandular elements of the mucous membrane, 
but which will sooner or later develop structural changes of a hyper- 
plastic character. 

In the latter case, hypertrophic rhinitis supervenes, the main fea- 
ture of which is persistent continuous obstruction to nasal breathing. 
The secretions are still apparently in excess. As a matter of fact, 
their proportion is reduced, but their quality is so perverted and the 
changed conditions so prevent their normal disposition, that they 
accumulate in the nasal chambers until removed by violent efforts at 
expulsion. The attempts at clearing the pharynx, especially in the 
morning, are often very distressing. These patients are habitual 
mouth breathers and snorcrs, and are apt to waken from sleep in the 
morning with the mouth and tongue dry and parched. Disorders of 
digestion are not infrequent, attributed perhaps unjustly to putrid 



42 DISEASES OF THE NOSE AND THROAT. 

and decomposing secretions finding their way from the pharynx to 
the stomach. The larynx may be affected and the voice becomes 
hoarse in consequence of the inspiration of improperly prepared air, 
the function of the nose being entirely or in part suspended. Among 
the more annoying, and at times painful symptoms of hypertrophic 
rhinitis, may be mentioned various reflex disturbances resulting from 
intranasal pressure. This subject has been actively investigated in 
recent years and many interesting phenomena have been discovered. 
It has been clearly demonstrated that very many functional disorders 
of the eye and notably of the ear may be due to a point of irritation 
or pressure within the nose. Facial neuralgia, frontal headache, 
cough and derangements of the voice may be attributable to a similar 
cause. The relief to ear symptoms following intranasal operations is 
sometimes very striking. Unfortunately, in many cases the aural 
difficulty has passed the line of purely functional disturbance before 
a nasal lesion is sought for or suspected. It is coming to be recog- 
nized that chronic turgescence of the turbinate erectile tissue and 
other nasal lesions, may induce vascular changes in the labyrinth as 
well as in the middle ear, so that it is safe to predict a considerable 
extension of the scope of intranasal surgery. On the other hand we 
must avoid the error of assuming that all human ills have a nasal 
origin. 

It is difficult to fix a line which separates the varieties of chronic 
rhinitis. The pathological processes merge into each other by such 
slow gradations that we frequently find several of them represented 
in the same subject. One nostril may be blocked by hyperplasia 
while the other is widely expanded in an advanced stage of atrophy. 

The diagnosis of an established case of atrophic rhinitis is usually 
easy, but the difficulty of identifying the two varieties of chronic 
rhinitis which have been described is greater. We rely upon inspec- 
tion, touch with the probe and cocaine to differentiate them. 

The first (hyperemia) presents a red tumefaction of the turbinate 
bodies, of uniform smoothness, which is quite sensitive and bleeds 
freely. It yields to compression with a probe, and in the early stages 
the pressure being released the tumor instantly reforms, owing to a 
reengorgement of the erectile tissue. Later on when vasomotor 
paresis occurs the furrow caused by the probe is more lasting. The 



CHRONIC RHINITIS. 43 

swelling promptly subsides under cocaine. In the second form 
(hyperplasia) the tumor is paler in color, irregular in contour, and 
less sensitive and vascular. Frequently, it is distinctly lobulated, 
papillated, or even fimbriated (Fig. 17). It is manifestly more 
dense in structure, may be compressed only by very firm pressure 
with the probe, and resumes its original shape very sluggishly. It 
does not completely shrink after an application of cocaine. 

In deciding upon a course of treatment it is important that we 
should distinguish these conditions. In the former case, sedative 




Fig. 17. Lobulated Hyperplasia of Left Inferior and Right Middle 
Turbinate. (Gritnwald.) 

applications, mild astringents perhaps, and the correction of vicious 
habits, notably the pernicious practice of violent nose blowing, will 
suffice. In the latter we have to deal practically with a foreign body 
which must be removed. 

Vaso-motor paresis of the walls of the blood-vessels composing 
the erectile tissue of the turbinate bodies is a prominent feature of 
the transition stage of hypertrophy. A physiological process thus 
gradually becomes pathological and the muscular walls of the venous 
sinuses undergo degeneration in consequence of which they remain 
permanently dilated until compressed and obliterated by the sur- 
rounding new connective tissue. This constitutes what is sometimes 
described as a " turbinal varix," seen usually at the posterior end and 
lower border of the inferior turbinate. Not infrequently, the osseous 
structures themselves become implicated in the inflammatory process, 
or undergo enlargement as a result of hypernutrition. A most inter- 



44 



DISEASES OF THE NOSE AND THROAT. 



esting series of pathological changes ensues involving chiefly the 
middle turbinate bone, which until recently has received but little 
attention. The bone may be simply thickened, or it may undergo a 
process of cystic formation or expansion. The inferior turbinate is 
but seldom thus affected, whereas in the case of the middle turbinate 
the discovery of these osseous cysts is a common occurrence. Their 
development is explained in various ways. In the majority of cases 
it doubtless results from a rarefying osteitis inducing absorption of 
the interior of the body of the bone. In other cases the cyst is be- 
lieved to be due to the prolongation of an ethmoid cell into the body 
of the middle turbinate and its subsequent expansion. In still other 
cases, and more rarely, as described bv Greville MacDonald, the 




Fig. 18. Cyst of Middle Turbinate Bone. (Author's specimen.) a, Nasal 
surface ; b, interior of cyst. 



mode of formation may be as follows : A hypertrophic rhinitis ex- 
tending from the soft parts to the periosteum covering the middle 
turbinate and finally to the bone itself causes its margin to curl out- 
ward and upward until it meets the body of the bone at some point 
where at length adhesions take place. The tube thus formed lined 
within and without by mucous membrane eventually becomes sealed 
at its extremities. Distention of this cavity goes on until the 
glandular elements in its lining membrane undergo absorption from 
pressure. The last explanation must certainly be considered rather 



CHRONIC RHINITIS. 



45 



fanciful. The developmental theory of etiology is accepted by Payson 
Clark, who professes to have found no evidences of inflammatory 
action in four cases of concha bullosa operated upon by himself, and 
who has discovered in literature only four cases accompanied by pus 
formation. On the other hand J. Wright points out the presence of 
osteoblasts building up bone on the outside of these cysts while 
osteoclasts are absorbing it within. Thus a preexisting cavity be- 
comes larger and larger as a result of a low grade of osteitis. These 
cysts are very common, Zuckerkandl having found them thirty-six 




I1F ; ' 




Fig. 19. Section of Bony Cyst of Middle Turbinate. (Author's specimen.) 

a, Layer of stratified epithelium ; b, layer of richly cellular vascular connective 
tissue, which is rather more dense about the laminae of bone, c-c-d ; e, layer of 
very loosely arranged edematous connective tissue resembling myxomatous tissue ; 
f, layer of ciliated epithelium ; g, layer of osteoblasts. 



times in 200 post-mortem observations. They are generally met with 
in adults and are more frequent in women than in men. 

The cyst sometimes reaches enormous dimensions, as shown in 
the accompanying plate (Fig. 18). The mucous membrane covering 



46 



DISEASES OF THE NOSE AND THROAT. 



it may persist in its hyperplastic condition, may become polypoid, or 
may atrophy. It is perhaps more usual to find it in the last men- 
tioned state. The tumor might readily be mistaken for a polyp or 
an ordinary hypertrophy unless carefully examined with a probe, 
when its hardness and immobility may be detected. Often the bonv 




ferts' Hand Atomizer. 



shell forming the wall of the cyst is so thin as to be readily punctured 
with a sharp probe (Fig. 19). 

Treatment. — In the early stages of chronic rhinitis we should en- 
deavor to soothe the irritated mucous membrane and to reestablish 
its normal functional activity. The warning against hasty and too 
free use of destructive agents at this period cannot be repeated often 




Woaxes' Nasal Irrigator 



Fig. 22. Nasal Syringe. 



enough. In our clinics many patients are met with who can distinctly 
trace their condition of incurable atrophy to excessive zeal in the use 
of caustics. Some, at least, of these might have been saved by mild 
measures, and by attention to the general health and mode of life. 



CHRONIC RHINITIS. 47 

It may prove to be necessary to cauterize, but before doing so in any 
case in which we cannot clearly define areas of hyperplasia, we 
should see what may be accomplished by diligent use of alkaline and 
antiseptic sprays or douches. Fluid applications may be made to the 
nares by means of an atomizer (Fig. 20), or of one of the various 
nasal douches (Fig. 21), cups or syringes (Fig. 22). The spray 
tubes as now made of very thick glass, in one piece, and with blunt 
tips, are entirely satisfactory (Fig. 23). Three styles are needed, up, 
down and straight. The first two should be five inches in length, the 



Fig. 23. Sass' Glass Spray Tubes. 

last need not be more than three or four inches from the angle to the 
tip. A hand ball, or one of the compressed air apparatus, according 
to convenience, may be used to form the spray. The pressure on the 
latter should not exceed twelve pounds, and often one half that 
degree of force will be ample, except with the heavier oily sprays. 

One of the best known solutions intended for use in this way is 
Dobell's solution (acid, carbolici gr. iv-x, sodas boratis, sodse 
bicarb, aa gr. xl, glycerin oiv, aquse ad oiv). The famous Seiler tab- 
let is quite as familiar to the laity as it is to the profession and in 
solution of proper strength is agreeable and satisfactory. One of the. 
best solvents for viscid secretion is warm salt water, in other words 
physiological or normal salt solution (7 parts to 1,000). In the 
majority of cases the most marked results will be obtained from 
menthol dissolved in fluid albolene (gr. ii-v to §i). Although oil 
and water will not mix and we cannot expect the mucous secretions 
and the albolene solutions to violate this law by showing an affinity 
for each other, yet we find that oily solutions serve a threefold pur- 
pose. They ensure gradual and prolonged action of the medicament 



48 DISEASES OF THE NOSE AND THROAT. 

which they may hold in solution or suspension, they prevent the in- 
crustation of secretion which is a more annoying feature of later 
phases of chronic rhinitis, and they furnish a protective film to the 
hypersensitive mucosa. It is true that sprays alone will not cure 
catarrhal conditions; it is true that oily solutions are disagreeable to 
some patients and act unfavorably upon some mucous membranes ; 
but the fact remains that the spray, properly used, is a valuable and 
an elegant agent for cleansing and medicating the upper air-passages, 
the larynx and pharynx, as well as the nasal cavities. It hardly need 
be said that medicated applications should be preceded by thorough 
cleansing of the surfaces especially in atrophic rhinitis when the nares 
are stuffed with hard and dry secretions. One of the best detergent 
solutions in common use is warm salt water, one teaspoonful of table 
salt to a pint. It is important to observe this proportion and all 
lotions to be used in volume from a cup, douche, or syringe are more 
agreeable and more effective if applied warm. Heating the spray 
mixture is less important since the temperature of atomized fluids 
falls almost instantly, but in cold weather the oils and heavy solutions 
may be sprayed more readily if previously warmed. The use of 
astringents to control hypersecretion would seem to be indicated, yet 
we find that drugs of this class are sometimes worse than useless, 
since the Schneiderian membrane often exhibits more or less intoler- 
ance of their action. The discomfort of the patient is sometimes 
markedly increased by them, their effect in checking secretion is very 
transient, and the sense of smell is in danger of being impaired by 
too vigorous and too frequent applications. The use of powders of 
various kinds has been popular at times, but they offer no advantage 
over drugs already in solution and are decidedly irritating unless 
great care is taken in their preparation. The least objectionable is a 
powder of stearate of zinc with boric acid which combines mild 
astringent with sedative and antiseptic properties and in certain cases 
seems to act favorably. Stearate of zinc is an excellent vehicle for 
other powders, such as aristol, europhen and iodol. It seems 
irrational, however, to ask the secretion of an inflamed mucous mem- 
brane to act as a solvent for these drugs, when the solution may be 
made more rapidly and accurately before their introduction to the 
nasal chambers. 



CHRONIC RHINITIS. 49 

The treatment of rhinitis at this period, therefore, consists mainly 
in the correction of bad habits, the regulation of diet, and the restric- 
tion of local measures to the use of remedies which tend to reduce 
congestion and thus to restore the normal function of the secretory 
glands. 

When the chronic catarrhal process has advanced to the second 
stage we are confronted by a totally different condition. Here cer- 
tain structural changes have taken place in the mucosa which lead to 
permanent narrowing of the nasal passages and which can be relieved 
only by surgical intervention. The method to be selected will de- 
pend largely upon the particular region affected. If nasal respiration 
is seriously interfered with, if nasal drainage is impeded, if neuralgia 
or other reflex phenomena can be traced to a point of contact or 
pressure within the nasal fossae, or if the sense of smell is impaired 
by an obstructive overgrowth, the indications for surgical interfer- 
ence are sufficiently clear. We rarely, if ever, meet with a lesion of 
this kind involving only the sense of smell. We may have reflex 
disorders or imperfect drainage, due to pressure, without respiratory 
stenosis. A lesion which prevents breathing through the nose can- 
not exist without interfering with drainage and generally weakens 
the sense of smell and provokes more or less reflex disturbance. 
Other considerations which should influence our choice of a mode 
of operating are the age of the patient, the duration of his difficulty 
and the temperament of the individual. In general the older and 
denser the hyperplasia the more energetic should be our attack upon 
it, but in children and in nervous subjects we may be forced to reject 
formidable apparatus and active agents for more tedious and less 
disturbing methods. Moreover, we must take care to avoid a violence 
in dealing with the middle turbinate body and the roof of the nasal 
chamber which may be exercised with impunity in the case of the 
inferior turbinate and the floor of the nose. If our patient is known 
to be a bleeder or if there is a reason for wishing to avoid even 
moderate depletion, of course, one of the bloodless methods of oper- 
ating is preferable. 

Hyperplastic tissue must be looked upon as a foreign body. There 
is no possibility of wholly restoring a mucous membrane thus 
affected. Until, therefore, the overgrowth is removed or reduced 
4 



50 DISEASES OF THE NOSE AND THROAT. 

by surgical measures or by the slower natural processes, we cannot 
reasonably expect any substantial relief of symptoms. The majority 
of these patients have tried the various advertised nostrums for 
" catarrh," or at least, have been in the habit of snuffing up salt water, 
before they apply for special treatment, and they may be considered 
fortunate if they have escaped troublesome complications, especially 
in the form of inflammation of the middle ear. Patients should be 
invariably cautioned against violently blowing the nose, especially 
with compressed nostrils, after the use of a nasal wash or douche. 
Excessive nose blowing which many with hypertrophic rhinitis prac- 
tice is damaging to the intranasal tissues as well as to the tympana. 
In washing out the nostrils the stream of fluid should always be 
thrown in by the narrower nostril, so that the return current may 
find unobstructed exit by the other nostril. 

There are three satisfactory ways of disposing of hyperplasia of 
the soft tissues of the nares : (a) By cutting operations with the 
cold wire snare, scissors, or forceps, (b) the electric cautery, and (c) 
chemical caustics. 

The cold wire snare is best adapted to extreme cases in which the 



1 " fry— ' 



E. B. MEYROWITZ, N. Y. 

Fig. 24. Jarvis' Cold Wire Snare. 

soft tissues protrude into the nasal passage to such a degree as to 
allow the wire loop to be well embedded (Fig. 24). If the surface 
of the hypertrophy is smooth and shades off into the adjacent parts 
it is very difficult to include the desired amount of tissue within the 
loop. To obviate this objection, Jarvis advises preliminary trans- 
fixion of the mass to be snared, the loop being then adjusted over the 
ends of the transfixion needle. Practically we find that this leads to 
the cutting out of a furrow of tissue along the track of the needle, 
if a single needle be used, and if several needles are applied the opera- 
tion becomes unnecessarily complicated. It is a good rule, therefore, 
to use the electric cautery for those cases in which the loop can not 
be employed without the aid of transfixion needles. A very ingenious 
suggestion by J. E. Boylan, who advocates ablation in preference to 
cauterization, seems to obviate the objection to transfixion needles. 



CHRONIC RHINITIS. 



5' 



The point of a fine tenaculum bent at a little more than a right angle 
is buried in the turbinate body where we desire the wire loop to cut 
and thus the amount of tissue included may be accurately determined 




Fig. 25. Sajous' Snares. 
a, Straight ; b, angular with three 



ips. 



by passing the loop over the hook. In order to prevent the anterior 
end from slipping a short incision is made in the base of the turbinate 
and in it the wire is inserted. The hot wire loop for these minor 



52 



DISEASES OF THE NOSE AND THROAT. 



operations within the nares is not to be recommended. With it there 
is danger of damaging adjacent parts which we wish to preserve. 
It should be reserved for those in whom we have reason to fear 
hemorrhage. For ordinary use Sajous' modification of Jarvis' snare 
is a most convenient instrument (Fig. 25). In tumors of unusual 
dimensions it will be necessary to use the original Jarvis snare, which 
permits unlimited expansion of the loop ; one end of the wire being 
fixed the other end may be played out to any extent desired. The 
Sajous snare, however, will carry a loop only so large as its screw 
thread will exhaust. The great advantages of the latter are the ease 
with which it is prepared for use and with which the loop may be 




Fig. 26. Wright's Snare. 



turned and manipulated, especially in a narrow nostril, from the fact 
that the ends of the wire are fixed at the distal end of the instrument. 
For polyps, neoplasms of medium size, and hypertrophies the Sajous 
snare meets every requirement. It will cut through not only the soft 
parts but the bone itself, and is especially adapted to cases of " mul- 
berry " hypertrophy of the posterior end of the inferior turbinate 
and to enlargement of the middle turbinate in which it is necessary 
to remove the anterior end of the bone (Fig. 26). In using the cold 
wire snare it is well to introduce as large a loop as the nostril will 
accommodate. If the patient is willing to endure the pain the loop 
may be adjusted before the use of cocaine, the inclusion of more 



CHRONIC RHINITIS. 53 

tissue being thus assured. There is no danger of getting too much 
tissue, as is true with some of the forceps devised for removing the 
turbinate bodies. The difficulty is to remove enough to relieve 
stenosis, and for that reason it may be desirable in some cases, for 
example, those in which the turbinate bone must be sacrificed, to use 




Fig. 27. Casselberry's Nasal Scissors. 



serrated scissors like those proposed by Casselberry (Fig. 27), or the 
author's cutting forceps (Fig. 28). In order to prevent hemorrhage 
the loop of the snare should be tightened very gradually. In vascular 
posterior hypertrophies, which are apt to bleed profusely, a half hour 
or more may be consumed in making the section. On the other hand, 
some patients prefer to have the snaring done quickly at the cost of a 
little more pain and loss of blood. By following the latter course we 
are apt to be informed at once of the amount of the bleeding, whereas 
otherwise, we may send our patient away with a feeling of security 
only to be summoned later to check a violent secondary hemorrhage. 
Since the introduction of cocaine episodes of this kind are said to 
have been more frequent, probably owing both to reaction from the 
temporary hemostatic effect of the drug and to the more rapid work 
which the local anesthesia permits. 

The electric cautery judiciously used, is one of the most valuable 
agents at our command. It has gained a measure of disrepute as a 
result of misuse. Unsuitable cases have been submitted to it, an 
improper degree of heat lias been employed, imperfect batteries and 
apparatus have been the source of great annoyance. As a result 
instances of violent inflammatory reaction, extending even to the 
meninges, have been reported, violent hemorrhage has followed the 
withdrawal of an excessively hot electrode, and batteries often failed 



54 



DISEASES OF THE NOSE AND THROAT. 



to work at critical moments. At the first sitting only a very moderate 
amount of burning should be done and the utmost care must be taken 
to exclude possible contraindications. An incipient febrile state or a 
condition of systemic depression may be sufficient reason for post- 
poning a cauterization, which is by no means always the trifling 
operation some profess to believe. Perhaps the most convenient 




Fig. 28. Author's Cutting Forceps, 



Dressing Forceps, b, and Scissors, c. 



source of the electric current for surgical use at present is the storage 
battery, of which there are several varieties in the market. Being port- 
able it may be used at the bedside as well as in the consulting room. 
It has the disadvantage of requiring frequent recharging according to 
the amount of work demanded of it. The selection of electrodes, 



CHRONIC RHINITIS. 



55 



handles and conducting cords is no less important. These articles 
are generally unnecessarily heavy and clumsy. In using electricity 
we should always remember that the result is accomplished by the heat 
and not by the application of force, hence, cumbersome apparatus is 
superfluous. The electrodes should be delicate, the handles light, 
and the cords not too thick and stiff. Attention to these details will 
add greatly to our comfort and satisfaction in using electricity. An 




Fig. 



Schech's Handle for Cautery Points. 



excellent set of electrodes for the nose, larynx and pharynx with 
handles of ebony and bone, is known as Schech's (Figs. 29 and 30). 
The Kuttner handle made of metal and vulcanite is very service- 
able, but is heavier. The degree of heat advised by most operators 
is "a cherry heat." Less heat fails to destroy to a sufficient depth 
and is more painful while much more than cherry heat is pretty 
sure to cause bleeding. With cocaine the question of pain does not 
arise, and if, as is to be preferred, the electrode is applied cold to the 
surface to be burned the degree of heat must be just on the border line 




ch's Handle for Cautery Loop. 



between cherry and white. Cocaine will be found of great service not 
only as an anesthetic, but in clearly defining areas of hyperplasia to 
be destroyed from other regions which are to be avoided by the 
electrode. The nostril to be operated upon having been thoroughly 
cleansed with an alkaline wash, cocaine in ten per cent, solution may 
be applied on pledgets of cotton, the head of the patient in the mean- 
time being bent forward to obviate the passage of the solution back- 



56 DISEASES OF THE NOSE AND THROAT. 

ward into the pharynx. In operating' far back in the naris the avoid- 
ance of this accident is impossible, and the patient should be fore- 
warned of the unpleasant consequences. Unless the nostril is ex- 
cessively narrow, a septal shield, or a special speculum for protecting 
the septum is not necessary. The cold platinum point being pressed 
firmly into the tissues the current is turned on for only a few seconds 
and no damage is done except at the line of contact. The electrode 
should be gently withdrawn before it has quite cooled. Otherwise, 
it adheres and its detachment causes bleeding. A little experience 
and care are needed to carry out this step of the manipulation suc- 
cessfully. We thus burn through the whole thickness of mucous 
membrane with two objects in view, first, to destroy redundant 
tissues and, second, to promote absorption by the resulting cicatricial 
contraction. Unless this secondary effect is kept in mind more burn- 
ing than necessary may be done. On the other hand, timid and 
superficial burning often does more harm than good by aggravating 
the irritable membrane. The cauterization should be thorough, but 
over a limited area. At the end of a week or ten days the burning 
may be repeated if it seems to be required. The use of a sharp- 
pointed electrode to be plunged into the submucous tissues has been 
proposed with a view of preserving as far as possible the surface 
of the membrane. As a matter of fact, in most cases which need 
to be burned the whole thickness of the mucosa is involved in the 
morbid process, and there is no object in attempting to save the sur- 
face. The foregoing observation applies with equal force to sub- 
mucous injection of acids or other solutions intended to shrink the 
tissues and to various ingenious plastic operations upon the turbinate 
bodies which have a similar end in view. Interest in these conserva- 
tive methods seems to have been recently revived and we find sub- 
mucous injections of zinc chlorid in ten per cent, solution advised by 
Gaudier, who however admits that results are uncertain and that 
cauterization or resection of the turbinate must be resorted to in 
many cases. The experience of Hamm, Viollet and many others 
authorizes the conclusion that a dense hyperplasia cannot be satis- 
factorily reduced in this way. The interstitial application of chromic 
acid is facilitated by the use of Goldstein's " turbinal trocar." The 
trocar and canula, the latter provided with an adjustable ring for 



CHRONIC RHINITIS. 57 

regulating the depth of insertion, are plunged into the hypertrophied 
tissues and after withdrawal of the trocar a probe armed with chromic 
acid is passed through the canula and drawn out together with it. 
Thus a line of caustic is deposited along the track of the instrument. 
Although these methods may be simple of execution, painless under 
cocaine, free from violent reaction and from the danger of adhesions 
we fail to see their advantage or efficacy in genuine hyperplasia, 
while in simple hypertrophy milder methods will generally suffice. 
In certain cases of nasal obstruction due to chronic turgescence of 
the turbinates from vaso-motor derangement Delavan proposes to 
effect retraction of the swollen tissues by submucous incisions, thus 
dividing and ultimately obliterating the venous sinuses. A very fine 
lancepointed knife or needle is used and one or two punctures are 
made at different points according to the extent of swelling. The 
results of this method are said to be permanent. 

Nearly all the chemical caustics, from strong nitric acid down, have 
been tried in hyperplastic rhinitis. They share the objection that, 
unless extreme care be exercised in applying them, they are apt to 
spread and burn over too wide an area. At the present time chromic 
and trichloracetic have supplanted other acids. There seems to be 
no decided choice between them, except on the ground that toxemia 
may result from the former in case it is applied too freely, or of 
individual idiosyncrasy. Chromic acid may be kept in crystalline 
form and at the moment of using a crystal or two may be fused on 
the end of a probe. A copper wire, five or six inches long, flattened 
at its end for half an inch, makes a good applicator. A few crystals 
are deliquesced by the addition of just enough water and the flat end 
of the probe is dipped in the thick solution. One side of the probe 
being wiped dry with a bit of absorbent cotton the other side re- 
mains charged with the acid. Thus armed the copper probe can do 
no harm to the septum, for instance, when we wish to burn only the 
turbinate body. The action of the acid is very prompt. It soon ex- 
hausts itself upon the tissues and there is no need to neutralize it 
unless an excessive quantity lias been accidentally used. Within a 
week the eschar thus produced separates or comes away in frag- 
ments and another application <>\~ the acid at the same spot is usually 
required. There is seldom any complaint of pain or reaction, except 



58 DISEASES OF THE NOSE AND THROAT. 

perhaps in neurotic subjects, or in case the application may have 
been extravagant. Some patients object to the disagreeable odor of 
chromic acid. In such the trichloracetic acid may be preferred. Its 
energy of action is almost, if not quite, equal to that of chromic acid. 
It is pleasanter to handle and is free from toxic qualities. It may be 
used with a Gleitsmann applicator, or may be applied by means of 
a fine nasal probe wound with a thin film of absorbent cotton. 

While the active treatment is being carried out local cleanliness and 
asepsis must be maintained by the use of sprays and irritating condi- 
tions of all kinds must be remedied as far as possible. The patient 
must be seen every two or three days and the formation of adhesions 
guarded against by the passage of a probe until healing and retrac- 
tion have well progressed. 

A form of nasal obstruction in which the inferior meatus is almost 
completely obliterated by thickening of all the tissues composing the 
inferior turbinate body is quite common. The current of air in 
respiration passes by the middle meatus while the floor of the nose 
is occupied by the swollen turbinate bathed in detained secretion. 
The drainage and ventilation of the nasal chamber are manifestly 
defective, and although the patient may respire through the nose by 
day he becomes a mouth-breather at night, the posterior nares and 
pharynx giving evidence of the latter. In order to remedy this con- 
dition the bone itself must be removed. This may be done with a pair 
of strong nasal scissors. The anterior end of the bone is usually 
most at fault and especially in a narrow nostril it is necessary to apply 
the blades of the scissors well down at the base of the turbinate. In 
extreme cases the saw or the cold snare works well, or one of the 
various conchotomes (Fig. 31) may be preferred. The so-called 
nasal plane, or spoke shave, has justly lost its popularity. It is apt 
to carry away too much tissue and many cases of alarming hemor- 
rhage after its use have been reported. The objects in view are to 
restore the normal patency of the nostril and leave a smooth sym- 
metrical stump. With strong solutions of cocaine (ten to twenty 
per cent.) and adrenal extract, this operation of turbinectomy, which 
should never be a complete resection of the bone, may be done pain- 
lessly and bloodlessly. Attempts at twisting off a turbinate body or 
avulsion with forceps are not to be recommended. The entire bone 



CHRONIC RHINITIS. 59 

might be dislocated by immoderate violence. Plugging the nostril 
except for hemorrhage does not seem to me desirable, although 
Lake's india-rubber splint, or similar dressings of celluloid are used 
by many. In the opinion of Pegler the rubber splint, which is asep- 
tic and easily removed and kept clean, saves the necessity of subse- 
quent trimming in consequence of the gentle uniform pressure it 
exerts upon the roughness inevitably left by the operation. Simp- 




Fig. 31. Berens' Spoke Shave. 

son's tampons of Bernays' compressed cotton, especially when cov- 
ered with rubber tissue, or by a thin sheet of vulcanite, as suggested 
by Chappell, arc sometimes useful in suppressing excessive granula- 
tion, but they must not be left in too long, and care should be taken 
not to use too thick a tampon lest in expanding it cause intolerable 
pressure. It is the belief of the author that most of these cases do 



60 DISEASES OF THE NOSE AND THROAT. 

better without such a foreign body in the nose even though it may 
not be very irritating. The case should be carefully watched dur- 
ing convalescence and exuberant granulations should be reduced 
with the knife or a light touch with the electric cautery. 

The use of hot air, first suggested by Vansant for the relief of head- 
ache, has been recommended in various morbid conditions of the nasal 
membranes by Lermoyez and Mahu and more recently by Lichtwitz. 
The current of air, at a temperature of 70 to 90 C, is propelled 
against the affected surface by a special mechanical device, consist- 
ing of an electromotor pump and an arrangement for warming the 
air, and is said to exercise a beneficial effect not only in simple en- 
gorgement of the erectile tissue but also to some extent in hyper- 
plastic conditions. It is possible to conceive that the nutrition of an 
affected area may be so changed by continuous or oft-repeated appli- 
cations of heat as to arrest a diseased process or possibly to promote 
absorption of inflammatory products, but a dense organized hyper- 
plasia would certainly not seem to offer a highly encouraging field 
for experiment with such a method. It is believed that more rapid 
and radical procedures will give more satisfaction. 

The question is often asked whether the results of treatment or 
operation will be permanent. In the majority of cases it is safe to 
answer in the affirmative provided the causes which instituted the 
catarrhal process can be discovered and eliminated. So many ele- 
ments are concerned in many cases, both as regards the individual 
and his environment, that it is not always possible to ensure this 
provision. But should signs of nasal insufficiency recur after a longer 
or shorter interval owing to reestablishment of hyperplasia that fact 
would be no reason for abstaining from treatment. It is a simple 
matter to repeat a cauterization if necessary, and the principle should 
be constantly kept in view that wholesale destruction of intranasal 
tissue is not the chief end of rhinology. Attempts to restore the 
function of crippled structures are far more commendable than sub- 
stitution of cicatrices for erectile tissue even though the latter be 
impaired. In many cases digestive or systemic derangements are of 
first importance, and endonasal surgery should be looked upon as a 
last resort. 



CHAPTER III. 

ATROPHIC RHINITIS. MEMBRANOUS RHINITIS. CASEOUS RHINITIS. 
PURULENT RHINITIS. 

Rhinitis atrophica must be considered a sequel of preexisting in- 
flammation rather than itself an inflammatory process. Various 
theories have been proposed to account for it. The majority of cases 
result from antecedent hyperplasia, the atrophic change in the nasal 
membrane being due to lessened blood supply from interstitial pres- 
sure which obliterates the vessels and at the same time interferes 
with glandular function. Some authorities believe in a primary 
atrophy and, in a certain proportion of cases, it is impossible to find 
evidence of preexisting hypertrophy. A third theory, of which Bos- 
worth is the principal champion, refers the atrophy to a purulent 
rhinitis as met with in children. Other observers, notably Cholewa 
and Cordes, maintain that the process begins in the bone, thence in- 
vading the mucous membrane. The argument in favor of this view 
is extremely plausible. Progressive bone absorption, due to causes 
not yet explained, obliterates the radical arteries and veins lying side 
by side in the bony canals, whence a portion at least of the blood 
supply of the soft parts is derived. In consequence the nutrition of 
the mucous membrane suffers and atrophy ensues. The causes which 
institute these alleged primary bone changes are not disclosed, but the 
admission of their existence in a measure explains the inefficacy of 
treatment in many cases of atrophy. Some authorities regard it as of 
neurotic origin, a trophoneurosis, and still others as consequent upon 
disease of the accessory sinuses. The constitutional dyscrasia gen- 
erally present is considered by some a result, by others a cause, of 
the nasal lesion. Congenital deformities of the nasal fossae, especially 
a short antero-posterior diameter, are looked upon as favoring an 
atrophic process. The discovery of certain bacteria in the secretions 
of an atrophic rhinitis has led to the adoption of a bacillary theory. 
Finally, a recent hypothesis is based on the observation that a meta- 
morphosis of columnar into squamous epithelium, or an " epithelial 

6\ 



62 DISEASES OF THE NOSE AND THROAT. 

metaplasia," may exist from infancy or birth. This condition is 
thought to be an etiological factor in intranasal atrophy, especially in 
the presence of marked disproportion between the vertical and 
lateral diameters of the skull, leading to abnormally wide nasal 
fossae. 

It is clear that no single theory will explain every case and that 
in some several of the causes, or conditions, mentioned may be con- 
cerned. From a clinical standpoint the evidence that hyperplasia 
tends to promote atrophy is conclusive, a view sustained by micro- 
scopic testimony. 

In the early stages of many cases of so-called atrophic rhinitis the 
pathological changes are limited to the mucous membrane and con- 
stitute a true fibrosis. Eventually bone involvement may occur. 
The latter is thought by some to be especially frequent in tubercular 
and syphilitic subjects. 

Malformations of the nasal fossae, particularly imperfectly de- 
veloped turbinate bones, and spurs and deviations of the septum are 
undoubtedly predisposing causes. Atrophy is apt to follow, also, 
various exanthematous diseases. It is usually met with rather early 
in life, a fact which has given prominence to the idea that purulent 
rhinitis is a predisposing cause. The influence of microorganisms 
is by no means determined ; their presence cannot be denied, but it 
is probably nothing more than a coincidence. The change in the 
membrane consists in the usual connective tissue overgrowth fol- 
lowing chronic inflammatory processes which results in contraction. 
This so-called submucous cicatricial contraction involves the blood- 
vessels as well as the glandular elements, the degree of functional 
disturbance and the prognosis depending upon its extent. 

The diagnosis of atrophic rhinitis may sometimes be made from 
the fetid odor alone. On inspection of a nasal fossa affected by 
atrophy the passages will be found more or less clogged with masses 
of inspissated secretion the removal of which exposes the membrane, 
pale in color and obviously thinned. The shrinkage may be universal 
or limited to certain areas and. on palpation with a probe, it is a 
simple matter to demonstrate the extent of the atrophied surface. 
In extreme cases, it is possible on anterior rhinoscopy to see the 
posterior pharyngeal wall and the action of the palatal muscles is 



ATROPHIC RHINITIS. 63 

plainly visible while the patient pronounces a nasal consonant. It 
is necessary to distinguish genuine atrophic rhinitis from two other 
conditions which resemble it in some respects. More or less con- 
fusion has prevailed and difference of opinion as to the prognosis and 
treatment has arisen from a failure to differentiate these various con- 
ditions. In the first place we should recognize the occasional exist- 
ence of a vascular collapse of the nasal erectile tissue accompanied 
by dryness of the mucous membrane. This is much more common 
in anemic persons and in the female sex. There is no characteristic 
physiognomy such as we see in advanced atrophy. The mucous 
membrane is pale and retracted on the subjacent bone. The condi- 
tion usually involves both nostrils. There may be no impairment 
of the sense of smell. There is no odor perceptible and the secretions 
are scanty. The condition may disappear under improvement in the 
general health and requires no attention locally. Secondly, there is 
a form of rhinitis with diminished mucous secretion, called rhinitis 
sicca which is observed in adults, usually of the male sex, in those of 
full habit and a gouty tendency. The mucous membrane, instead of 
being pale, is congested and tends to become hypertrophied. The 
turbinate bodies may be turgescent. There may be erosions, espe- 
cially of the septum, possibly accompanied by perforation. Fre- 
quently the condition is unilateral, but it is generally seen on both 
sides. It is not readily curable by local measures alone, but im- 
proves under the use of antilithic remedies. 

The symptoms of atrophic rhinitis relate chiefly to disturbances 
caused by altered secretion. The mucus loses its fluid, serous charac- 
ter, tends to become rapidly inspissated, and form characteristic 
crusts or scabs which attach themselves firmly to the mucous mem- 
brane and are very difficult to remove. The retention of these crusts 
is due not only to their character but to the fact that abnormal widen- 
ing of the nasal passages prevents the blast of expired air from 
exerting its usual force. The disappearance of the cilia from the 
epithelium, a constant phenomenon in atrophy, is no doubt an im- 
portant factor in derangement of secretion. True ulceration of the 
mucous membrane is rare, but, when it exists, is a result of the habit 
of picking the nose to dislodge accumulated secretion. Nosebleed 
may result from violent attempts to clean the passages by blowing, 



64 DISEASES OF THE NOSE AND THROAT. 

The patient has a constant feeling of stuffiness and desire to blow the 
nose even when the accumulated material is not excessive. One of 
the most distressing symptoms in bad cases is the fetid odor, or 
ozena, a term which is mistakenly applied by some to the disease 
itself. It should be reserved for the symptom of the disease since 
ozena is met with not only in atrophic rhinitis but in syphilis, malig- 
nant disease, and in obstruction from a foreign body or from de- 
formity or disease of the nasal fossae. It is much more pronounced 
in some cases than in others. If the patient himself has lost the 
sense of smell it may not be perceptible to him. Fetor seems to be 
quite independent of the quality and the quantity of secretion, fre- 
quently being very marked when the latter is scanty. No doubt in 
some cases the fetor may be traced to secretions retained in an acces- 
sory sinus, but pronounced ozena is not unusual when these adjacent 
cavities are above suspicion. In certain individuals there seems to be 
some inherent quality in the tissues or secretions whence emanates a 
peculiar odor analogous to that sometimes observed from the sweat 
glands. There is seldom any pain although the patient may com- 
plain of a dull, heavy sensation over the bridge of the nose and in 
the frontal region. On the other hand severe headache especially in 
the forehead may occur. Many patients show rather sluggish mental 
operations and are very apt to be depressed in spirits. Not infre- 
quently secondary disturbances of the pharynx and larynx occur 
and gastric derangements are often met with and, sooner or later, 
distinct impairment of the general health is noticed. The latter 
fact, in conjunction with an obstinate cough often present, is 
likely to excite apprehension of lung disease. In well-marked cases 
a peculiar facial expression, shown in the widely expanded nostiils, 
snub-nose, the dull countenance and thick lips, is thought to be 
characteristic. 

The treatment of atrophic rhinitis has in view two objects; the 
correction of the fetid odor and the restoration of glandular function. 
The former is always feasible, the latter is not when the process of 
degeneration has advanced to an extreme degree. The fact that the 
disease, if not caused by a constitutional diathesis is certainly aggra- 
vated by a depressed state of the general health suggests the neces- 
sity of combining local with general treatment. The use of tonics. 



ATROPHIC RHINITIS. 



65 



attention to hygiene and the correction of digestive derangements 
are of the greatest importance. 

The internal use of mucin, especially with a view to its influence 
upon secondary derangements of the digestive tract, has recently 
been urged. It is given in tablets containing five grains each of 
mucin and bicarbonate of soda. A watery solution is used as a 
douche to the nose and pharynx. It is said to counteract the dryness 
of the membranes and to relieve the gastrointestinal disorders which 




Fig. 32, 



Lefferts' Post-nasal Syringe. 



are a frequent consequence of deficiency of normal mucous secretion 
due to atrophy. 

In approaching the question of local treatment we are amazed at 
the large number of drugs which have been resorted to at various 
times. The inference is that in general experience the disease has 
been found rebellious to treatment. So true is this that many practi- 
tioners conclude that cleanliness is all that can be accomplished by any 



Mil'.': 



/M 



\ 




Fig. 32, b. Holmes' Post-nasal Douche. 

course of treatment whatever. While this may apply to the worst 
cases of atrophic rhinitis, nevertheless if the process be identified at 
its inception much may be done. There is no question that thorough 
cleansing of the surface is important before medication should be 

5 



66 DISEASES OF THE NOSE AND THROAT. 

attempted. The removal of the dried secretion is often a very diffi- 
cult process and cannot be effected by the patient himself, at least, 
at the outset of treatment. Simple douching of the nose or spraying 
is only a partial mode of accomplishing the end and must be sup- 
plemented by systematic brushing of the surface of the mucous 
membrane with sterilized cotton wound on the end of a nasal probe. 
It is a good plan first to soften the secretions thoroughly by means 
of a coarse spray or douche of normal salt solution as hot as the 
patient can comfortably bear. In some cases when the crusts invade 
the nasal pharynx it is necessary to cleanse from behind forward by 
means of a post-nasal syringe, or Holmes' post-nasal douche (Fig. 
32). Having removed all the secretions we are prepared for the 
application of an agent which will stimulate glandular action pro- 
vided the glands have not been entirely destroyed. One of the best 
applications for the purpose in most cases is a solution of menthol in 
albolene in the proportion of ten grains and upwards to the ounce. 
Weak solutions are useless. This may be applied twice a day after 
the use of the salt water. An excellent stimulating application is 
a solution of formaldehyde, one of the best preparations of which is 
borolyptol which contains 1 to 500 of formaldehyde. This must be 
still further diluted since it is very irritating, but it has the double 
advantage of stimulating the mucous membrane and acting as a 
powerful deodorant. Citric acid in powder with an equal quantity 
of sugar of milk has been observed to control the fetor and crust 
formation. Nitrate of silver, in solution of twenty to sixty grains to 
the ounce, or even stronger, has been widely used, but seems to offer 
no advantage over other preparations less disagreeable to handle. 
Some of the modern compounds of silver, argonin, protargol and 
argentamin, may be destined to find a permanent place in therapeutics. 
Hydrogen dioxid finds favor with many practitioners and among the 
preparations recently introduced may be mentioned the so-called 
peroxoles, three per cent, solutions of peroxid of hydrogen combined 
with menthol, camphor, naphthol, and so on. and known respectively 
as menthoxol, camphoroxol and naphthoxol. They seem to have 
been used with good results in a great variety of conditions attended 
by suppuration with the effect of prolonging the well-known bac- 
tericidal action of the hvdrogen. The characteristic effervescence 



ATROPHIC RHINITIS. 6"/ 

and foaming soon subside and the application is said to be entirely 
free from irritating properties when used of suitable strength. Tam- 
pons of gauze soaked in a ten or fifteen per cent, solution packed in 
the nostril and renewed once or twice in twenty- four hours will lessen 
crust-formation and ozena. A combination of equal parts of men- 
thoxol, camphoroxol and sterilized water acts very well. 

An ideal antiseptic, if all that is claimed for it be true, is offered 
in gomenol, a vegetable product said to possess extraordinary germi- 
cidal power while being free from irritating properties. It is the 
ethereal oil of Melaleuca viridfflom, a. plant growing near Gomen in 
New Caledonia. A ten per cent, solution in olive oil, to which 
a few drops of oil of pine, or oil of wintergreen, have been added, is 
an agreeable and effective application. One of the best preparations, 
provided its odor is not objectionable, is ichthyol, which may be used 
in a five per cent, solution in kerolin or, as preferred by many, in 
much stronger solution, or even in a pure state over a limited area. 
Its unpleasant odor is sometimes a bar to its use as regards others 
if not so far as the patient is concerned. When a deformity or 
stenosis interferes with nasal drainage or forms a site for the lodg- 
ment of secretion it should be removed ; otherwise no intra-nasal 
operation is advisable. Superficial erosions usually undergo repair 
without special attention as the secretions and the membranes acquire 
a more healthy character. In some cases a dilated naris, due to devia- 
tion of the septum, admits an excessive volume of air which may 
be reduced by wearing a film of absorbent cotton in the nostril or by 
replacing the deflected septum. Some of these patients are persistent 
mouth-breathers, although the nares are sufficiently spacious. They 
complain that they cannot feel the air in breathing through the nose, 
a state of things due to anesthesia of the mucosa, or merely to ex- 
cessive width of the passages. The idea of making an artificial turbi- 
nate by means of submucous injections of paraffin has been sug- 
gested by Richard Lake. In a case of bone absorption the abnormal 
width of the nasal canal was counteracted by bolstering up the soft 
parts with five-minim injections of paraffin made at weekly intervals 
until a body of proper size was formed. The relief of discomfort 
was complete. A similar proposal lias been made by Brindel, who 
claims to have observed a disappearance of the tendency to stagna- 



68 DISEASES OF THE NOSE AND THROAT. 

tion and drying of secretion and an actual restoration of normal 
glandular function. 

The great interest in serum therapy naturally excited the hope that 
something might be accomplished in that line in atrophic rhinitis. 
Experiments have been made by different observers and there is ^yide 
divergence of opinion as to the results. Some claim to have cured 
advanced cases by the repeated injection of ten centimeters of Roux's 
diphtheria antitoxin. Others pronounce this dose excessive and 
allege that the treatment is dangerous and inconvenient although it 
gives positive results in the disappearance of dryness and crust for- 
mation with the relief of ozena. This is not likely to supersede safer 
and equally efficacious modes of treatment. 

In addition to the medicinal agents already mentioned for treat- 
ing atrophic rhinitis we have at command various resources more or 
less serviceable. Xasal bougies, medicated or otherwise, have been 
used. Plugs or tampons of cotton have been recommended with the 
idea of partially obstructing the nasal passages for the purpose of 
reducing barometric pressure. The result is more or less congestion 
of the mucous membrane with increased functional activity. The 
method of Gottstein consists in packing the nasal fossae with dry non- 
absorbent wool which is renewed at the end of twenty-four hours. 
Thus a tendency to crust-formation is corrected, a more healthy 
action of the glands is established and the mucous secretion becomes 
more fluid. 

Another method of dealing with certain cases in which there are 
localized areas of diseased tissue consists in the use of the sharp 
curette. This is adapted only to very limited areas of eroded granu- 
lar mucous membrane underlying tenacious crusts or scabs of decom- 
posing secretion. It must be used with caution, since, as already said, 
our efforts should be directed mainly to the preservation and resto- 
ration of tissue. Electrical treatment of atrophic rhinitis is applied 
in the form of the galvano-cautery in cases similar to those in which 
the curette is admissible ; second, by the constant or interrupted cur- 
rent; and, third, by electrolysis. Their effect with the exception of 
that first named consists in stimulation of glandular function and is 
effective in cases not too far advanced. These methods are tedious 
and require frequent repetition and special apparatus. The use of 



ATROPHIC RHINITIS. 69 

galvanism gives excellent results in suitable cases, that is, those in 
which the glands have not been completely obliterated by the atrophic 
process. A flat sponge electrode connected with the positive pole of 
a constant current battery is applied to the nape of the neck. The 
negative pole, a metallic electrode, is placed in direct contact with 
the mucous membrane of the nose. It is rather more agreeable to the 
patient to use in the nose a copper wire electrode loosely wound 
with absorbent cotton. If both nostrils are to be treated the nasal 
attachment may be double, a section for each nostril, as suggested by 
Delavan. The strength of the current should not exceed seven 
milliamperes and the duration of each sitting should not be more 
than twelve minutes. The patient feels a sensation of warmth but no 
pain, unless the current is too strong. A slight watery secretion is 
excited by the application and in course of time the quality of the 
nasal mucus is perceptibly improved. 

Cupric electrolysis is warmly commended by some observers. 
Strong currents are very painful and a general anesthetic may be re- 
quired. Watson Williams, who claims better results with this than 
with any other method of treatment, prefers mild currents at in- 
tervals of two or three weeks until increased secretion and vascularity 
and diminished fetor are noted. The parts having been cocainized 
" a copper needle attached to the positive pole is inserted into the 
tissues of the inferior or middle turbinated body, and a steel needle, 
attached to the negative pole, into the septum, and a current of from 
five to ten milliamperes is passed from ten to fifteen minutes." This 
process should be repeated until the symptoms yield and on signs of 
recurrence. The results of vibratory massage are not especially en- 
couraging and the proposal of Flatau to excite tissue proliferation 
and increased secretion by driving ivory pins into the turbinate bone 
will hardly appeal to a large number. 

Spontaneous recovery sometimes takes place, that is the symptoms 
cease although normal tissues may not be regenerated. In adoles- 
cents approaching puberty and in women at the menopause ameliora- 
tion follows when these critical periods have been passed. What- 
ever course of treatment be selected in a case of atrophic rhinitis pro- 
nounced results must not be expected in weeks or even months. 
The secret of success lies in the early adoption of a systematic regime 



JO DISEASES OF THE NOSE AND THROAT. 

which includes both local and general medication and which must be 
continued with persistence. 



MEMBRANOUS RHINITIS. 

An inflammation of the nasal mucosa characterized by the forma- 
tion of a membranous or fibrinous exudate is occasionally seen in 
which the membrane shows no tendency to invade the pharynx and 
which is not attended by any indications of constitutional disturb- 
ance. The condition differs from diphtheria in being a much milder 
type of disease as regards local as well as general disturbance. There 
may be some rise of temperature and a good deal of nasal stenosis 
but there is no sign of sepsis and the disease is not contagious. It 
differs from diphtheria, also, in that glandular involvement is rare, 
the diphtheritic odor is absent and the Klebs-Loeffler bacilli seldom 
can be found. The membrane is easily removed and generally re- 
forms. Similar conditions are seen after the use of strong caustics 
in the nose and after the galvanocautery especially in those depressed 
in health and ill nourished. The importance of the diphtheria bacillus 
in membranous inflammations is opened to question by the discovery 
by Meyer of large numbers of virulent bacilli in membrane formed 
after the use of the galvanocautery as well as in a majority of cases 
of fibrinous rhinitis. In a great variety of nasal diseases examined 
by Vansant the mucous secretion showed the presence of the diph- 
theria bacillus in a large percentage. Pluder believes that fibrinous 
rhinitis is really a mild form of diphtheria, having found the bacillus 
in all of five cases examined microscopically. Either the Klebs- 
Loeffler bacillus is of no consequence, or else there exist " true " and 
" false " bacilli which even expert microscopists differentiate with 
difficulty. Unless the possibility of infection be conceded the con- 
dition cannot be regarded as very important and active interference 
is not indicated. In some cases general tonics may be desirable and 
the comfort of the patient may be increased by gentle removal of the 
membrane and applications of antiseptics and mild astringents in oily 
solution. 



CASEOUS RHINITIS. PURULENT RHINITIS. J I 

CASEOUS RHINITIS. 

The name caseous rhinitis is given to a rare and curious form of 
inflammation in which the nasal passages are occupied by a material 
resembling cheese or putty. It is said by some to develop in strumous 
individuals and in connection with nasal polypi. It would seem to 
be a result of fatty degeneration of secretion which has been long 
retained either in an accessory sinus or in the upper part of the nasal 
fossa?. A prominent symptom is a sensation of stuffiness in the nose 
accompanied by headache. The sense of smell is usually lost and the 
fetor always present is not apparent to the patient. This state of 
things may be corrected by careful attention to cleanliness, the 
cheesy mass being thoroughly removed and the nasal cavities after- 
wards sprayed with antiseptic solutions. At the same time the 
morbid condition which gives rise to the perverted secretion must be 
found and eradicated. In a recent case in my own clinic an intoler- 
ably offensive mass of cheesy accumulation was removed from the 
nose of a fairly intelligent man whose only complaint was of head- 
ache and nasal stenosis. Such a condition could result only from 
the grossest neglect. This disease must not be confounded with a 
false rhinitis cascosa. The latter is always dependent upon a foreign 
body, a rhinolith, a tumor, or a chronic sinusitis, while in the true no 
such cause can be found. Its dependence upon a specific microbe, 
the Streptothrix alba, as described by Guarnaccia, and its relation to 
scrofula, as maintained by Cozzolino and others have recently been 
stoutly denied by Michele. Its rarity, the rapidity of its cure, the 
absence of recurrence, a single case having been reported by Massei, 
added to the fact that the disease is practically unilateral would seem 
to exclude a scrofulous origin. According to Michele no specific 
microbe can be found, hence if we accept this observer's views we 
shall still be in the dark as to the etiology of the disease. 

PURULENT RHINITIS. 
Purulent rhinitis is a variety of catarrhal inflammation of the 
mucous membrane in which pus formation is the prominent symp- 
tom. It is not intended to include in the term that form of rhinitis 



J2 DISEASES OF THE NOSE AND THROAT. 

which occurs as a specific infectious disease transmitted to the new- 
born from the vagina of the mother. It occurs, as a rule, in infants 
as a result of exposure to irritants, either in the air or in the secretions 
of the maternal passages. The nasal discharge is very irritating and 
produces excoriation of the upper lip, and both nostrils are usually 
affected. There may be but little obstruction to nasal breathing. 
The secretion is more or less odorous, especially if the nostrils are 
not faithfully cleansed. A mucous membrane affected in this way is 
apt to be permanently impaired. By some observers this condition 
is believed to be an invariable precursor of atrophy. 

The treatment consists in careful cleansing of the nasal passages 
by an alkaline antiseptic solution, followed by an application of mild 
astringents. In many cases, indications of struma or constitutional 
impairment demand general as well as local treatment. 

A purulent nasal discharge in a child may be symptomatic of 
adenoids in the rhinopharynx. It may occur in syphilis or as a result 
of gonorrheal infection ; in the former case the usual constitutional 
treatment is indicated, and in the latter precautions must be taken to 
prevent contagion, and to protect the eyes. 



CHAPTER IV. 

DISEASES OF THE ACCESSORY SINUSES. ACUTE AND CHRONIC SINU- 
SITIS. HYDROPS ANTRI, OR SEROUS EFFUSION AND CYST OF 
THE ANTRUM. FOREIGN BODIES AND NEOPLASMS. 

The accessory sinuses when inflamed present certain features in 
common which may be considered before discussing individual 
cavities. 

Acute sinusitis may occur in connection with a "cold-in-the-head " 
either as a result of direct infection or of swelling of the nasal mucous 
membrane which causes a damming up of secretion. It is met with 
in the course of the exanthemata, of typhoid, diphtheria and ery- 
sipelas, and has been particularly observed as a complication or sequel 
of influenza. Acute inflammation of the sinuses may, also, follow 
traumatism and many cases are on record in which a foreign body has 
been driven into the frontal or maxillary sinus with the result of 
causing an acute empyema. The sphenoidal sinus and the ethmoid 
cells are less exposed to injury but similar cases have been reported 
in connection with these cavities. A blow on the face has been known 
to cause inflammation of the antrum and a case has been recorded 
by Rees in which empyema of the antrum in a child two weeks old 
resulted from compression of the head at birth. A tendency to spon- 
taneous cure of an acute process undoubtedly prevails in the absence 
of any lesion or anatomical peculiarity which may act as an obstacle 
to evacuation of the products of inflammation. 

A symptom invariably present in acute sinusitis is pain, as a rule 
referred to the region of the affected cavity and accompanied in the 
case of the frontal and the maxillary sinus by sensitiveness on ex- 
ternal pressure, and by swelling and possibly edema of the overlying 
soft parts. 

A chronic sinusitis may follow an acute attack, or may be charac- 
terized by the absence of acute symptoms from the outset. The pain 
associated with chronic sinusitis is seldom intense and its situation 
is often of but little diagnostic value. For example, supra-orbital 

73 



74 DISEASES OF THE NOSE AND THROAT. 

pain may be a symptom of antral rather than frontal sinus disease. 
In ethmoidal disease the pain is usually referred to the bridge of the 
nose, while in sphenoidal disease the back of the head is chiefly 
affected. A unilateral discharge of pus in the adult is always sug- 
gestive of sinus disease although bilateral sinusitis is by no means un- 
common, having been found by Wertheim in 38.7 per cent, of cases 
of maxillary empyema. As a rule, the discharge is intermittent and 
is affected by change of posture ; in other words a position that makes 
the outlet of the sinus more dependent facilitates drainage. A pecu- 
liar musty odor is generally present which may be perceptible to the 
patient himself. This is more marked in antral and ethmoidal dis- 
ease than in empyema of the frontal sinus. The location of the pus 
is to some extent a guide as to its origin. Its color also is more or 
less distinctive, that from the antrum being light yellow or canary 
colored. It is probable that the variation in the physical characters 
of the purulent secretion in different cases is to be explained in part 
by the great variety of microorganisms found in these conditions. 
The subject has been carefully investigated by Stanculeanu and Baup, 
whose conclusions are interesting and may be of value with reference 
to determining the origin of a sinus empyema. Antral suppurations 
are divided into two groups. In the first there is an antecedent his- 
tory of dental or alveolar disease and the pus has a decided fetor, due 
to the presence of anaerobic bacteria, or those whose growth is not 
dependent upon oxygen. The second group comprises those be- 
lieved to be of nasal origin, the sinusitis followed an acute rhinitis, 
the teeth are sound and the secretion is mucopurulent and ropy. The 
pus is not fetid and is found to contain aerobic organisms, or those 
which grow only in the presence of oxygen. Further examination 
shows that microbes of the former kind inhabit the buccal cavity 
and are rarely found in the nose. The aerobic variety is met with in 
the nasal cavity and the purulent secretion it excites is more mucoid 
in character and is quite free from fetor. The pneumococcus either 
alone, or more frequently together with other microbes, is the organ- 
ism most often found in the latter. In dental empyemas various 
bacilli may be discovered— ramosiis, perfringens, serpens, tlicto'idcs 
and fragilis and Staphylococcus parvulus in order of frequency — all 
exhibiting marked virulence when injected into animals. Similar re- 



THE ACCESSORY SINUS. 



75 



suits were obtained in investigating the frontal sinus. In one case 
both forms of bacteria were found, the frontal sinusitis being con- 
secutive to an antral empyema of dental origin. 

In cases of nasal suppuration in which sinus disease is suspected, 
the nostril having first been thoroughly cleansed of secretion, it is 
sometimes possible to detect a leakage of pus from the middle 
meatus under the concavity of the turbinate body, from which fact 
we infer an affection of either the maxillary sinus, the frontal sinus, 



'-■rfckLTrr/ 




f/D/l. 



Fig. 33. Sound in (a) Frontal, (fc) Anterior Ethmoidal and (c) Maxillary 
Openings. (Hajek.) 
f.s., Frontal sinus; o.e., ostium ethmoidale ; m.t., middle turbinate cut off; 
s.t., superior turbinate; sp.t., supreme turbinate; p.e.c, posterior ethmoidal cells; 
sph.s., sphenoidal sinus. 

or the anterior ethmoidal cells. If pus is seen over the convexity of 
the middle turbinate, or between it and the septum, it is probably 
flowing from the posterior ethmoidal cells or the sphenoidal sinus. 
Escape of pus from the antrum may be encouraged by directing the 
patient to throw the head well forward and towards the sound side. 



y6 DISEASES OF THE NOSE AND THROAT. 

When the patient lies down the pns flows backward and causes a bad 
taste in the mouth with gastric disturbance and morning nausea. 
The existence of polypi in the region of the middle meatus is apt to 
complicate an empyema of the antrum, or of the frontal sinus, or of 
the ethmoidal cells, whether as cause or result is often hard to deter- 
mine (Fig. 33). 

There seems to be no doubt that the accessory sinuses are affected 
by an inflammatory process much more often than has been supposed 
until within recent years, a fact explained in part by the prevalence 
of crude and superficial methods of examination and in part by the 
obscurity of symptoms in a large proportion of cases. Very many 
cases are put down as " nasal catarrh," and indeed in some of long 
standing those affected have no complaint to make except of moder- 
ate excess of nasal discharge. This statement is corroborated by the 
post-mortem researches of E. Fraenkel, Harke and others. From 
studies conducted at Lichtwitz's clinic, where 243 cases of sinusitis 
were diagnosed in 12,000 patients, and from results announced by 
other observers, F. Martin concludes that indications of sinusitis are 
fifteen times more frequent in the cadaver than in the living subject. 
This discrepancy is accounted for in acute cases by the relatively 
greater prominence during life of symptoms referable to the general 
disturbance and in chronic cases to the latency of symptoms located 
in the sinus which renders a diagnosis difficult. Post-mortem rec- 
ords are not to be altogether relied upon, since pus in a sinus does 
not always mean inflammation where the fluid is found, and more- 
over inflammation if present may have been a recent development 
in the fatal illness and hence failed to attract attention during life. 
The obvious lesson is that a cursory inspection of the nasal fossae 
should not end the examination of a case of nasal suppuration. 



THE MAXILLARY SINUS. 

The antrum of Highmore, being the largest and most accessible 
of the sinuses, was supposed to be especially prone to suppuration 
until more exact and thorough methods of exploration taught us that 
the other adjacent cavities, notably the ethmoid cells, are involved 
with equal or greater frequency (Fig. 34). 



THE MAXILLARY SINUS. 



77 



An acute inflammation of the antrum tends to resolve under favor- 
able conditions, that is, provided drainage through its normal outlet 
be 'adequate. The orifice of this cavity being much higher than its 
floor, when the patient is erect, and liable to occlusion from swelling 
of the soft parts in its vicinity, an acute process is apt to degenerate 
into a chronic empyema. Acute maxillary sinusitis is said to be more 
frequent in men than in women. It may occur quite early in life. 
J. H. Bryan quotes Pedley as authority for a case in a child eight 
years old following caries of a canine tooth, and Shurly refers to a 




Fig. 34. Vertical Cross Section Through Posterior Part of Nasal Foss/e 
Showing Their Relations to Adjacent Parts. (Zuckerkandl.) 
A, Roof; B, floor, and / outer wall of cavity; aaa, superior, middle and in- 
ferior meati ; b, middle turbinate bone ; c, olfactory fissure, and d, respiratory 
fissure. 

case noted by Power in a child eight weeks old due to traumatism by 
forceps during delivery, while Moure reports two cases in infants 
three weeks old from premature eruption of a tooth-, one of the chil- 
dren being syphilitic. Bryan also describes an extension of nasal 
diphtheria and of phlegmonous pharyngitis to the antrum. When 



?8 DISEASES OF THE XOSE AND THROAT. 

the inflammatory products are pent up within the cavity the symp- 
toms are so intense as to leave no doubt about the diagnosis, and ex- 
plorative puncture is never necessary. In treatment the indications 
are to subdue local reaction by warm applications externally and to 
promote drainage by reduction of swelling in the middle meatus. 
Cocaine, adrenal extract and sprays of menthol usually give relief. 
In exceptional cases the ostium must be enlarged, the middle turbi- 
nate removed, or puncture through the inferior meatus or the canine 
fossa must be done. In a small proportion of cases the products of 
an acute inflammation are retained in the antrum and undergo case- 
ation. All inflammatory symptoms may have subsided, but the 
decomposing pus emits a most offensive odor the real source of 
which may not be suspected. Removal of the inspissated pus by 
irrigation through the normal outlet or by an artificial opening 
dispels the fetor (Avellis). In looking for a cause of chronic 
empyema of the maxillary sinus it is necessary to make a careful ex- 
amination both of the teeth and of the nasal chambers. It is still sup- 
posed that most of these cases may be traced to dental caries, but we 
have come to believe that a very large proportion owe their origin to 
a catarrhal inflammation affecting the middle turbinate and its neigh- 
borhood. Nevertheless, a tooth apparently sound at its crown may 
be a source of mischief from a carious process going on at its root. 
Moreover, septic infection may be conveyed by the lymphatics from 
a point of decay in the crown of a tooth, the root of which may be 
free from disease (Grunwald). M. H. Cryer, who has made careful 
study of this subject, believes that more teeth are lost from antral 
disease than primarily cause it, an opinion fully confirmed by E. S. 
Talbot, whose investigations have been exceptionally thorough and 
extensive. In other words, it is often necessary to seek a cause of 
antral empyema elsewhere than in the alveolus. It is sometimes pos- 
sible on anterior rhinoscopy to distinguish well-marked bulging 
toward the nasal fossa of the outer wall of the nose. There is likely 
to be some swelling of the face on the affected side together with 
sensitiveness on pressure or percussion. It has been claimed that 
dulness on percussion may detect a diseased sinus and succussion has 
been mentioned as a diagnostic sign, but it must require an excep- 
tionallv keen ear to srain anv data of value from either. In some 



THE MAXILLARY SINUS. 



79 



cases, especially those of dental origin, the alveolus on the affected 
side is swollen, congested and sensitive to pressure. If any doubt 
remains as to diagnosis we may resort to exploratory puncture with 
a trocar, either through the inferior meatus, or the canine fossa. In 
the latter case an ordinary small-sized trocar and in the former the 
curved antrum trocar designed by Myles will be found convenient. 
This should be done with the strictest antiseptic precautions, lest a 
sound antrum be thereby infected (Fig. 35). Hydrogen dioxid in- 
jected into the antral cavity through the ostium as proposed by 
Moreau Brown, is relied upon to give its characteristic effervescence 
in the presence of pus, but should be used cautiously, since the rapid 
evolution of gas may produce painful distension. Pus may some- 




Fig. 35. Myles' Antrum Trocar, Canula and Washing Tube. 

times be seen oozing from the antrum alongside a probe or canula 
passed through the ostium. With a Politzer bag attached to the 
canula, or air douche, one sometimes succeeds in expelling small 
quantities of pus that cannot be washed out by any process of irriga- 
tion. Secretion may sometimes be sucked out of an affected sinus 
by the process known as " negative politzerization " as recommended 
by Sestier. The diagnosis may be further confirmed by transillumi- 
nation of the sinus by means of an electric lamp placed in the mouth 
(Fig. 36). This test is more satisfactory in a room from which all 
other light is excluded. Illumination of the face beneath the orbits 
is thought by Davidsohn to be less conclusive than that of the eyes, 
which are usually bright in a normal skull with a clear antrum. 
Exploratory puncture sometimes fails, owing to extreme density of 
the antral wall, which the trocar cannot penetrate, or to thickness of 



8o 



DISEASES OF THE NOSE AND THROAT. 



the pus whereby it is prevented from flowing through the canula. 
Transillumination demonstrates the presence of pus reliably, pro- 
vided we eliminate certain sources of error, but under no circum- 
stances should its exclusive testimony be accepted as final. By ex- 
amination with the fluorescent screen even more exact information 
may be gained than with the ordinary electric light in transillumina- 
tion, but for this special expensive appliances are required. The in- 
vestigations of Zuckerkandl and others have shown that variations 





Fig. 36. A, Heryng's Lamps for Transillumination ; B, Meyrowitz' Electric 

Lamps. 

from the normal anatomical type are so frequent that we are liable 
to be led astray by certain abnormalities in the structure of the skull 
which alter the relations and dimensions of the sinuses. The remark- 
able diversity in the size of the antrum in different individuals is 
shown by the observations of Cattlin, quoted by Heath. It is larger 
in the male than in the female, it contracts in old age, while in very 



THE MAXILLARY SINUS. 8 I 

young subjects it is extremely small or may be entirely absent. He 
also notes the fact that subdivisions of the cavity by bony ridges and 
that extensions of the antrum into the malar bone, the alveolus, or 
posteriorly are far from infrequent. Perfect symmetry is practically 
unknown. It is easily seen, therefore, how the accuracy of the light 
test may be impaired. For instance, a relatively small antrum may 
transmit a deficient amount of light, as compared with the opposite 
side. A thickened lining membrane and anomalies in the bony wall 
of the antrum may interfere with this test. The larger the antrum 
and the thinner its wall the more brilliant will be the light test. 
Mucocele and cyst of the antrum are said to exaggerate the intensity 
of the light. In a case of the latter under my own observation this 
phenomenon was obvious in consequence of expansion of the antral 
cavity and attenuation of its anterior wall from pressure. Until the 
light test was employed this was supposed to be a solid tumor in 
consequence of its firmness on palpation. Dentary cysts become of 
special interest to the rhinologist only when they invade the nasal 
fossa, or, as in the foregoing case, the antrum. Unless the cystic for- 
mation begins at the very root of a tooth the swelling is more likely 
to present itself along the alveolus, obliterating the canine fossa and 
finally distending the jaw and perhaps the roof of the mouth. The 
contents, usually thin and clear, may be reddish or coffee-colored, 
rarely resembling pus (F. C. Cobb). In the latter case, or if there 
is much inflammatory thickening of surrounding tissues, the light 
test may show more brilliancy on the sound side. The persistence of 
translucency in the presence of polypi is illustrated in a case recently 
reported, in which the antral cavity was filled with ordinary mucous 
polypi (Lambert Lack). In addition to the extent of the light area 
in the antral region, normally most intense just beneath the margin 
of the orbit, we may get more or less reliable information from the 
appearance of the pupils and from the presence or absence of per- 
ception of the flash of light on the part of the patient when his eyes 
are closed. In a large proportion of cases in which there is no antral 
anomaly the pupils are brightly illuminated and the patient is con- 
scious of a flash when the current is passed intermittently. Having 
several times seen the light test frustrated by failure to remove a 
superior dental plate it seems to me not superfluous to call attention 
6 



82 DISEASES OF THE NOSE AND THROAT. 

to the necessity of this precaution. The following instructive case 
from my clinic at the Manhattan Eye and Ear Hospital exemplifies 
an error into which we may be led even after the use of every diag- 
nostic resource. 

A young man was admitted with a fluctuating tumor about the size 
of a hickory nut at the root of the left lateral incisor of the upper 
jaw. It had been in existence two months and was quite painless and 
insensitive. There was no history of nasal suppuration. Two years 
ago the jaw was injured by a fall in skating, and a carious tooth 
was subsequently extracted. Transillumination showed both sides 
of the face equally bright. With an exploring needle passed through 
the alveolus creamy pus was withdrawn, and on free incision the 
abscess appeared to communicate with the antrum. In fact the case 
was pronounced by several an empyema of the antrum. But on more 
careful examination it was possible to demonstrate that a cavity ex- 
isted above this abscess and was separated from it by a firm bony 
wall, as proved by exploration with the probe and finger. The case 
was one of suppurating dentary cyst, a diagnosis further confirmed 
by the absence of symptoms pointing to the antrum as well as of pus 
discharge from the nasal passages. The abscess cavity slowly filled 
with granulation tissue and became obliterated, but it is easy to see 
how the antrum might have become infected as a result of excessive 
surgical zeal. 

The use of the tuning fork in differentiating a diseased from a 
healthy antrum has recently been proposed by D. A. Kuyk, but its 
practical value remains to be determined. The sound waves are said 
to be transmitted feebly if it all through a sinus occupied by fluid, 
being heard louder and longer through an empty antrum, even 
though of small size and enclosed by thick walls. 

It has been suggested that the source of a nasal suppuration may 
be determined by plugging the orifices of the sinuses in succession 
by means of cotton or gauze and then observing when the flow is 
controlled (Griinwald). In view of the difficulty in locating the 
anatomical outlets of the various sinuses and of the frequent anoma- 
lies in their situation this procedure is not of very practical value. 

The fact must not be overlooked that even if pus is present in the 
antrum it may not have been generated there, since it has been proven 



THE MAXILLARY SINUS. 83 

that this cavity may act as a reservoir for pus formed in the frontal 
sinus or anterior ethmoidal cells. Examination is not complete until 
we have explored the other accessory cavities for the possible ex- 
istence of suppuration in them. J. H. Bryan has described an ex- 
ample of direct communication of the frontal with the maxillary 
sinus, so that pus secreted in the former must inevitably have 
accumulated in the latter. He also quotes Fillebrown as having 
observed many cases in which the infundibulum ended below in a 
pocket so situated in front of the ostium maxillare as to direct a flow 
of pus from the frontal sinus into the antrum, the discharge not 
appearing in the nasal passage until the antrum and the abnormal 
infundibular pocket became filled. Probably some of the cases of 
" latent empyema " reported by Lichtwitz, Jeanty and others, re- 
markable for the absence of subjective symptoms, may be explained 
by the existence of this anomaly. Obviously a diagnosis of suppu- 
ration originating in the maxillary antrum should not be hastily 
assumed. 

The diagnostic features upon which we rely when present offer an 
unmistakable picture. Some or all of them may be so feebly pro- 
nounced as to justify the term " latent empyema." 

The following may be enumerated as the most trustworthy signs 
of chronic abscess of the antrum : 

1. Nasal suppuration. Pus may be seen flowing from the middle 
meatus and it is sometimes possible to exclude the ethmoid cells and 
the frontal sinus as sources of the discharge. 

2. Pain, dull aching, or merely a feeling of tension in the antral 
region with more or less prominence of the face over the antrum and 
bulging inward of the wall of the nasal fossa. 

3. Swelling, redness and sensitiveness on pressure along the 
alveolus on the affected side. Carious, sensitive teeth may be found. 

4. Transillumination shows the suspected side in shadow, the pupil 
of the corresponding side is dark, and the patient himself sees less 
clearly or fails to see the flash of light with the eye of that side. 

5. Pus may be withdrawn from the cavity of the antrum by means 
of an aspirating trocar passed through the ostium, the canine fossa, 
or the inferior nasal meatus. 

In many cases of chronic sinusitis the mental depression and gen- 



84 DISEASES OF THE NOSE AND THROAT. 

eral disturbance are out of all proportion to the activity of the 
process going on within the antrum. Patients often complain of 
neuralgia, ill-defined headaches and lack of mental concentration 
which are almost incapacitating. It may be possible to explain such 
conditions by supposing an impression upon the nerve centers from 
more or less absorption of suppurative products. At any rate it 
is usual to observe improvement in these particulars after free exit 
has been given to the discharge and pus formation begins to sub- 
side. 

The treatment of chronic empyema of the antrum must be con- 
ducted on general surgical principles ; namely, the abscess must be 
thoroughly evacuated and cleansed of all diseased material. A cari- 
ous tooth may protrude into the cavity, polypoid degeneration of the 
lining membrane, or necrosis of the bony wall may each be present 
and share in perpetuating the suppurative process. Disease in- 
volving the ostium maxillare, either deflection of the septum, nasal 
polypi, or enlargement of the middle turbinate in such a way as to 
interfere with drainage, must receive attention. A carious molar or 




Fig. 37. Myles' Antrum Tubes of Soft Rubber. 

bicuspid tooth should be extracted and the antral cavity entered 
along its socket. At the same time care should be taken to ensure 
a free opening of the anatomical outlet into the nose so as to give 
perfect through drainage. Sound teeth should never be sacrificed, 
but an opening may be made into the antrum through the canine 
fossa sufficiently large to admit a curette or even the finger for pur- 
pose of exploration. When the antrum is entered through the 
socket of a tooth or through a small alveolar opening it is customary 
to introduce a tube of soft rubber, vulcanite or silver (Fig. 37), 
through which the cavity may be drained and irrigated. Its outer 
aperture is usually provided with a plug for use during eating. The 
anterior end of the middle turbinate, if enlarged and obstructing the 
middle meatus, should be removed with a snare or forceps. 

Objection is sometimes made to opening the antrum through the 



THE MAXILLARY SINUS. 



85 



mouth on the ground of danger of reinfection of the sinus from the 
buccal cavity. To obviate this the antrum may be entered by plung- 
ing a curved trocar, or the spear-pointed " stilet " of Mikulicz (Fig. 
38), through the outer wall of the nasal fossa in the inferior meatus. 
Thus an aperture is made quite near the floor of the cavity. Some- 
times the bone is so thick and dense as to be pierced with difficulty, 




Mikulicz' Antrum Stilet. 



and, moreover, unless a considerable portion of the wall of the 
meatus is removed it is often impossible to keep the opening free. 
The most serious argument against this method is that it gives us 
no opportunity to explore the interior of the antrum and after all 
a more radical operation may be required to effect a cure. While 
subsequent free exposure of the cavity through the alveolus, or the 
canine fossa is by no means precluded by previous puncture through 
the inferior jneatus it is believed that cases cured by the latter route 
alone might have been relieved by way of the ostium maxillare. 
In a small proportion of cases of empyema of the antrum the 




Fig. 39. Hartmann's Canula. 



cavity can be entered and washed out through the natural opening. 
For this purpose a canula shaped somewhat like an Eustachian 
catheter, fitted with an ordinary piston syringe or rubber bulb, will 
be found convenient (Fig. 39). In seeking the opening in the 
antrum the canula should be introduced with the beak directed 



86 



DISEASES OF THE NOSE AND THROAT. 



towards the concavity of the middle turbinate and passed well back 
into the middle meatus. It is then turned outward and drawn for- 
ward until its tip catches in the uncinate process, when by firm 
pressure upward and outward we sometimes succeed in entering 
the antral cavity. It may be necessary to remove the tip of the tur- 
binate, or to correct a septal deformity, in order to introduce the 
canula (Fig. 40). 

The solution used for cleansing the cavity should be bland and 
unirritating. A warm two per cent, boric acid or normal salt solu- 
tion answers as well as any. An attempt to cure antral empyema 




Fig. 40. Snare Applied to Anterior End of Middle Turbinate. (Hajek.) 

by this means should not be persisted in too long, since failure to 
give relief in this way in from four to six weeks is certainly indica- 
tive of degenerative changes in the mucous membrane lining the 
antrum or of its wall, which require to be overcome by more radical 
methods. 

The following case illustrates how a sinusitis may be kept up by 
retention of a foreign body in the cavity of a sinus. The patient 
was a lady about thirty years of age who had had a molar tooth 
extracted. Immediately after the operation the fluid used to cleanse 
the mouth was observed to escape from the right nostril, indicating 
that the tooth had perforated the floor of the antrum. The aper- 



THE MAXILLARY SINUS. 87 

ture in the alveolus closed in a few days and an offensive purulent 
discharge from the nose appeared. About one year later the antrum 
was drilled through the canine fossa and irrigation practiced for 
some weeks. The discharge ceased but recurred and the washings 
were resumed. The patient then went on very comfortably for a 
period of five years when she became rather run down in health, 
had frequent attacks of cold in the head and was, most of the time, 
conscious of an offensive odor in the nose. She suffered more or 
less from hemicrania and a dull aching sensation in the region of 
the antrum. The anterior end of the middle turbinate was removed 
and the antrum was syringed through the ostium maxillare. The 
discharge gradually ceased and remained absent for a year when it 
recurred with all the original symptoms. The antrum was then 
opened freely by A. B. Duel when a calculous mass, the size of a 
small bean, was found lying in the cavity. On section this proved 
to be the fang of a tooth encrusted with salts. The antral opening 
was kept free for three or four weeks ; when all discharge had ceased 
it was allowed to close. The cure seems to have been permanent. 

A similar case recorded by Macintyre is of interest especially from 
the fact that the foreign body, a lost drainage tube which had slipped 
into the antral cavity, was demonstrated with the X-rays. 

In doubtful cases the latter expedient may be of great value, and 
it has even been proposed to utilize it for guiding the drill with pre- 
cision and safety in opening the frontal sinus through the nose. It 
is said that the position and direction of the drill, which should be 
not more than three millimeters in diameter, are defined with abso- 
lute accuracy (G. Spiess). 

In cases of long standing when pus discharge continues to be pro- 
fuse and offensive by all means the best method of treatment is 
what is described as the Caldwell-Luc operation. The anterior wall 
of the antrum is exposed by an incision along the gingivo-labial fold 
of the upper jaw and the muco-periosteum reflected. The bony wall 
is then perforated by a drill or trephine and the opening enlarged 
with bone-cutting forceps, until it is possible to make a thorough 
inspection of the interior of the cavity. Thus, the existence of 
trabeculae and of areas of polypoid degeneration, as well as necrosis 
which would otherwise escape observation, may be detected. Should 



Ob DISEASES OF THE NOSE AND THROAT. 

conditions of this kind be discovered the cutting forceps and curette 
must be used with freedom, after which the cavity is washed out 
with an antiseptic solution and packed with iodoform gauze. The 
gauze should be removed at the expiration of twenty-four hours, 
and irrigation repeated daily until suppuration ceases. Gradual 
contraction of the opening takes place, and, as a rule, no measures 
are required to close it. After a time the irrigation of the cavity 
may be entrusted to the patient who readily learns to manipulate 
the syringe used for washing. 

In his operation for the radical cure of maxillary sinusitis Luc 
advocates the formation of a muco-periosteal alveolar flap, and of 
a drainage opening in the inferior nasal meatus through which the 
end of the gauze packing is to be brought, with the intention of 
closing the buccal wound by means of sutures. Practically, closure 
of the incision by stitching is found to be unnecessary. It is difficult 
to keep the wound perfectly aseptic and the stitches are apt to tear 
out or the wound to become infected. The parts are found to unite 
readily if disturbance is avoided by care as to diet and movements 
of the mouth. 

Removal of the anterior end of the inferior turbinate body is rec- 
ommended by some as a first procedure with a view to making a 
drainage opening through the antral wall in the inferior meatus. If 
the turbinate is removed before the antrum is opened it may be nec- 
essary to control hemorrhage by packing the nostril with iodoform 
gauze. Some operators prefer to postpone this step until the close 
in order to avoid annoyance from bleeding. The incision in the 
mouth is best made from the first molar tooth forward toward the 
frenum and should be extensive enough to give ample space for the 
use of the chisel or trephine. At the moment of incising the lining 
membrane of the antrum free hemorrhage often occurs. It may be 
readily controlled by firm pressure for a few moments with iodo- 
form gauze. It is said to be modified very much by the preliminary 
injection of cocaine or better suprarenal extract solution. 

Failures in the radical operation may result from overlooking the 
existence of areas of polypoid degeneration, or bony septa, which 
partially, or perhaps completely, subdivide the antral cavity. In a 
recent case of my own a firm bony partition divided a very large 



THE MAXILLARY SINUS. 89 

antrum by projecting from its floor nearly to its roof. Without care 
and thorough exposure of the parts it might easily have escaped 
observation. The case referred to is also interesting as illustrating 
the condition of so-called " latent empyema " in which the symptoms 
were so obscure that a positive diagnosis of sinus suppuration was 
very tardily accepted. 

The opening in the nasal fossa through the inferior meatus should 
be made large enough to give good drainage and obviate the danger 
of premature closure. If made too small it may have to be re- 
opened every few days ; if made large it is possible to dispense alto- 
gether with drainage tubes and gauze dressings, a very desirable 
object, since it is believed that many cases of antral suppuration are 
kept up by too energetic postoperative meddling. A generous open- 
ing, moreover, permits us to entrust the care of the case to the 
patient himself. 

In some cases of chronic antral disease the transillumination test 
will show the absence of accumulated pus immediately after opera- 
tion. In most of them, however, the changes in the bony wall and 
mucous lining are so extensive that the light is not transmitted for 
several weeks, and possibly, not at all. This fact is noted by De 
Roaldes, every one of a series of cases operated upon by Gordon 
King and himself showed opacity after a cure of the empyema had 
been pronounced. 

The use of astringent applications to the interior of the cavity 
during convalescence may be sometimes required. As a rule, sim- 
ple cleansing by means of antiseptic irrigation is all that is neces- 
sary. Sometimes a solution of chlorid of zinc, twenty per cent., or 
protargol solution, ten grains to the ounce, or one quarter of one 
per cent, nargol solution, a combination of silver and nucleinic acid, 
seems to assist in arresting the suppurative process. In others, the 
formation of pus ceases almost at once and, in from four to six 
weeks, a cure is established. 

Tt is necessary to refer to the so-called dry treatment of sinus sup- 
puration by insufflation with various powders, which is practically 
the introduction of a foreign body into a cavity already sufficiently 
irritated, to condemn it without reservation. 

As a precaution against recurrence attention should be given to 



gO DISEASES OF THE NOSE AND THROAT. 

the condition of the nasal membrane and to the removal of any 
obstacle from the region of the antral orifice. It is impossible to 
emphasize too strongly the importance of this point, as well as the 
avoidance of meddlesome interference with a reparative process by 
excessive irrigation with strong solutions, or by plugging the antral 
cavity with sterilized or medicated gauze for too long a period. 

In most cases an artificial opening into the antrum gradually con- 
tracts and closes. Occasionally its track has to be stimulated by 
cauterization. In exceptional cases a permanent fistula remains, and 
it has been my experience to see several such cases in which the con- 
dition caused little or no inconvenience. The continuance of dis- 
charge after operation may be explained by complications which have 
already been adverted to, namely, the persistence of pyogenic mem- 
brane in a pocket or adventitious sinus overlooked at the time of 
operation, or the presence of some neglected nasal anomaly, or finally 
the fact that the antrum is acting as a receptacle for pus overflow- 
ing from the frontal sinus or the ethmoidal cells. Moreover, the 
influence of the general health upon a suppurative process should 
be remembered, and if indicated measures tending to improvement 
in that direction should be adopted. 



FRONTAL SINUS. 

Inflammation of the frontal sinus is a frequent complication of 
an acute coryza and is prone to lapse into a chronic condition in the 
presence of any occlusion of the hiatus frontalis. One of the earli- 
est symptoms in acute cases is pain in the supraorbital region either 
upon one or both sides according as one or both cavities are in- 
volved. In a small proportion of cases there is but one frontal sinus, 
no median septum being present (Fig. 41). An exceedingly rare 
condition has been described by Suarez de Mendoza, in which two 
sinuses on either side, one behind the other, were found. They 
communicated by small openings with each other and each opened 
into the nose by a separate passage. It may be that such an anomaly 
might render its possessor more prone to sinus disease, and it is 
easily seen that any therapeutic measures, surgical or other, are 
thereby made more difficult and complicated. Pain may be intense, 






THE FRONTAL SINUS. 



91 



neuralgic in character, aggravated by blowing the nose, or a stoop- 
ing position, or it may consist of simply an aching sensation, or a 
sense of dullness or weight. There is marked tenderness along the 
supraorbital ridge and especially on deep pressure under the supra- 
orbital arch. Frequently there are puffiness and swelling of the 
skin over the affected sinus and of the upper eyelid, and sometimes 
slight pitting under compression. These symptoms subside with the 
occurrence of a purulent nasal discharge, or distension of the cavity 



^i/8fe 




Fig. 



Normal Frontal Sinuses of Average Size. (Logan Turner.) 



may be followed by exophthalmos and formation of an orbital 
abscess. 

The diagnosis based on the foregoing symptoms is usually free 
from difficulty. Transillumination offers a less reliable diagnostic 
sign in case of the frontal sinus than with the antrum owing to the 
well-known fact that asymmetry of the former is much more fre- 
quent (Fig. 42). A small electric lamp, covered except at its end 
by an opaque shield, pressed well under the supraorbital arch, defines 
the boundaries of the frontal sinus quite accurately. By using a 
lamp on either side simultaneously, or a double transluminator like 
that devised by H. S. Birkett, it is possible to compare the sinuses 
by illuminating both at the same moment. Thus the rays of light 
are thrown upward through the floor of the sinus. The single lamp 



DISEASES OF THE NOSE AND THROAT. 



being placed at various points on the forehead, meanwhile the patient 
being directed to keep his eyes closed, he himself can map out the 
sinuses with considerable precision by noticing when the light be- 
comes perceptible as it is shifted about. By what they call " medio- 
frontal " illumination, Lubet-Barbon and Furet have demonstrated 
that by placing the lamp in the median line of the forehead a differ- 
ence in intensity of the light may be observed under the supraorbital 
arch. Logan Turner, whose researches in this field have been very 
complete, finds many interesting anomalies and variations in the 





Fig. 42. Asymmetry of Frontal Sinus. 
a, Right sinus almost obliterated and left subdivided by numerous septa ; 
b, small right and very large left sinus. {Logan Turner.) 

frontal sinuses and concludes that the light test is of little or no 
practical value in chronic suppuration in these cavities, his view 
being based on the following grounds : " ( 1 ) One or both sinuses 
may be absent, and 'when this anatomical condition exists, there is 
opacity on one or both sides of the skull. (2) A certain proportion 
of healthy sinuses fail to illuminate ; this may occur on one or on 
both sides of the skull. (3) A sinus on one side of the skull may 
illuminate with less brilliancy than its fellow, although both are per- 
fectly normal. (4) Many sinuses containing pus, and with their 



THE FRONTAL SINUS. 



93 



mucous membrane thickened and often polypoid, illuminate with 
considerable intensity." Darkness may indicate no sinus, a thick- 
walled sinus, or a diseased sinus, so that in most cases we must 
arrive at a diagnosis by other means. In chronic cases the absence 
of subjective symptoms may necessitate reaching an opinion by ex- 
clusion. If pus quickly reappears in the middle meatus, the antrum 
having been emptied of purulent contents by syringing through the 
ostium and the patient's head being held quite erect, the source of 




Fig. 43. Septa of Frontal and Sphenoidal Sinuses. (Schadle.) 



pus must be either the frontal sinus or the anterior ethmoidal cells. 
Even in so-called " latent " cases a certain degree of tenderness on 
the affected side may be elicited by firm pressure upward against the 
floor of the sinus. In cases of the latter class also there is apt to 
be at times more or less swelling somewhere in the region of the 
sinus. In some cases a positive diagnosis can be made only by 
catheterizing the sinus through the frontonasal canal with a Hart- 



94 DISEASES OF THE NOSE AND THROAT. 

mann or Krause canula, a feat often very difficult of accomplish- 
ment. The passage may be tortuous, or it may be necessary to 
resect the anterior end of the middle turbinate or other obstacle 
before a probe or canula can be passed. The end of the probe 
may become engaged in an anterior or fronto-ethmoidal cell, or may 
be arrested by an irregularity in the canal, but if it seems to have 
some freedom of movement and has passed a distance of not less 
than six or seven centimeters from the floor of the nose the pre- 
sumption is that it has entered the sinus (Fig. 43). 

In the treatment of a frontal empyema the first essential is the 
correction of any lesion or obstruction in the nostril. The tendency 
to spontaneous cure is certainly more pronounced than with the 
other accessory sinuses provided drainage through the anatomical 
outlet can be restored. If the case is allowed to pursue its own 
course discharge of the abscess may take place into the middle 
meatus through the frontonasal canal, or it may rupture into the 
orbit where the wall of the sinus is thinnest, outward through the 
external table, or through the inner table into the cerebral cavity. 
In a case of long standing which occurred in my own clinic the 
abscess pointed at the outer limit of the superciliary ridge ; in the 
meantime by pressure upon the eyeball producing symptoms which 
had led the patient to consult an oculist. The abscess was opened 
by the usual free incision when the nature of the case was demon- 
strated. The best method of treating a chronic frontal sinusitis is 
undoubtedly by external operation which naturally leaves more or 
less of a scar but gives reasonable assurance of cure. In attempt- 
ing the relief of the case through the nose we are handicapped by 
being obliged to work in a very narrow passage and, moreover, 
opportunity is not given to make proper exploration of the sinus 
cavity. Indeed it is very rarely possible to enter the sinus by pass- 
ing a probe along the frontonasal duct. One is quite as likely to 
get into the anterior, or fronto-ethmoidal cells, or even altogether fail 
to find the orifice of a canal. The latter has been the experience of 
more than one operator after complete extirpation of the middle turbi- 
nate body. The feasibility of guiding the drill or trephine through the 
nasal fossa to the floor of the sinus by means of the Roentgen ray 
has been mentioned in speaking of abscess of the antrum. In most 



THE FRONTAL SINUS. 95 

cases the lining membrane has undergone a degenerative process 
which necessitates thorough curettage. In not a few caries or necro- 
sis of bone may have taken place. Under such circumstances sim- 
ple drainage is not sufficient to accomplish a cure and the only ra- 
tional mode of treatment is to make free exposure of the cavity by 
what is known as the Ogston operation, or one of its modifications. 
An incision is made from the supraorbital notch toward the middle 
line, including the skin and periosteum, which are then reflected and 
the anterior wall of the sinus is opened by means of a trephine, hand 
drill, or a chisel. If more room is needed a vertical incision may be 
made in the median line at an angle with the first. Sufficient bone 
should be removed by means of cutting forceps to enable one to 
explore the walls of the cavity thoroughly and to pass a drainage 
tube through the fronto-nasal duct into the nasal fossa. The cavity 
having been thoroughly cleansed and irrigated with an aseptic solu- 
tion, the external wound is closed with sutures, a drainage tube 
being passed through the nasal opening for the purpose of irriga- 
tion. So long as signs of suppuration appear with the irrigating 
fluid used for washing the cavity the tube should be retained. Usu- 
ally in the course of a week or ten days it may be safely withdrawn. 

Various modifications of the original operation for frontal sinus 
disease as proposed by Ogston have been suggested. Most sur- 
geons prefer to go through the anterior wall even at the risk of 
considerable deformity resulting, which is apt to be the case when 
nearly all of the wall is removed, as in the operation performed by 
Kuhnt and others. In an ingenious modification proposed by R. W. 
Payne, several openings are made into the affected sinus, intermedi- 
ate bridges of bone being left to serve as a supporting framework 
to the soft parts. The insertion of a plate of aluminum, platinum, 
decalcified bone, or ivory to lessen the disfigurement has been sug- 
gested by Semon, but so far as I am aware has not been attempted. 
Paraffin prosthesis is likely to prove useful in this direction. 

In order to obviate deformity the following method of operating 
is described by Lothrop (Fig. 44). A curved incision is made from 
near the nasofrontal suture upwards parallel with the folds of skin 
formed by the corrugator supercilii muscle for about fifteen milli- 
meters, gradually curving outwards and following the horizontal 



9 6 



DISEASES OF THE NOSE AND THROAT. 



folds. With a drill or trephine an opening is made through the 
wall just above the supraorbital arch at the inner angle of the orbit 
and below the inner extremity of the superciliary ridge. According 
to Lothrop the existence of a diploe in this situation may be relied 
upon to show the absence of a frontal sinus, and none being found 
pus, if present, must come from the ethmoid cells. But this cannot 
be altogether trustworthy, since in several instances to the author's 




Fig. 44. Incisions in Opening Frontal Sinus. (Lothrop.) 
1, Anterior wall. Osteoplastic operation, the bone flap thus formed is de- 
flected downwards. 2, Floor, giving access also to ethmoidal cells. 

knowledge both cancellated tissue and sinus have been absent. In 
one hundred crania examined by Max Scheier the frontal sinus was 
absent five times, and other anomalies were frequent. 

Through the opening thus formed the cavity is probed to deter- 
mine its dimensions and possible changes in its mucous lining. If 
the sinus is found to be very spacious, the opening must be enlarged 



THE FRONTAL SINUS. 97 

by chiseling a bone flap along the line of incision with the supra- 
orbital arch serving as a base. This bone flap may readily be pried 
downwards and fractured along the thin orbital surface of the sinus 
and is to be replaced at the conclusion of the operation. The advan- 
tages claimed for this method are that the sinus may be well opened 
and that a large opening may be made into the nasal fossa without 
disturbing the orbit. 

The frontal sinus may also be entered through its inferior surface, 
giving a less perfect exposure of the cavity but rendering the eth- 
moid cells very accessible and being followed by somewhat less 
deformity. Without the exercise of great care there is, however, 
more danger of disturbing the orbit or interfering with the lachry- 
mal apparatus. This is sometimes known as Jansen's operation. 
The objection to it last mentioned is very serious while it is by no 
means absolutely free from disfiguring effects. 

In this operation the incision commences opposite the inner can- 
thus, in front of the margin of the orbit, over the nasal process of 
the superior maxilla. It curves upwards and outwards along the 
eyebrow to the supraorbital notch. The periosteum is elevated and 
the flap turned down so as to expose the internal angular process 
of the frontal bone. Hemorrhage may occur from the supraorbital 
and angular arteries and may be controlled by pressure or by liga- 
ture. The bony wall of the sinus is opened by means of the chisel 
just above the internal angular process of the frontal bone where 
the bone is thinner than on the anterior surface and more easily per- 
forated. If pus escapes through the operative wound at once we 
have reason to believe that the frontal sinus is affected ; if not, the 
presumption is that nasal suppuration arises from the ethmoid cells 
which may be easily reached through this wound. The most im- 
portant step in these operations is the establishment of roomy com- 
munication with the nasal fossa by removal of the anterior ethmoid 
cells. A small probe is passed through the ostium into the nose to 
be used as a guide. The finger may be introduced into the nostril 
in order to give the curette the right direction, which should be 
downward and somewhat backward. Practically, this consists in 
removal of a greater part of the lateral mass of the ethmoid which 
fills in the meatus frontalis and, if thorough, no drainage tube will 



98 DISEASES OF THE NOSE AND THROAT. 

be required. The external wound is closed completely and pro- 
tected with a sterile dressing and the nostril is packed with iodoform 
gauze for twenty-four hours. 

In the after-treatment the irrigation of the nasal fossa should be 
gentle so as to avoid disturbing the wound in the skin and should 
be limited to a warm two per cent, boric acid solution. The patient 
should be especially warned not to blow the nose until the wound 
is thoroughly healed. 

Sometimes the external wound fails to unite completely, especially 
in cases where disease of the sinus has been extensive or the bone 
has been involved. As a rule, however, union takes place kindly 
and the relief of symptoms attributable to pressure is almost imme- 
diate. 

The method of operating practiced by Luc and that recently pub- 
lished by Herbert Tilley differ in some minor details from the pro- 
cedures just described. The former seals up the external wound 
and brings a gauze drain from the sinus to the anterior naris, the 
gauze being removed after two or three days. In Tilley's opera- 
tion the anterior end of the middle turbinate and all polypoid and 
granulation tissue and dead bone are first removed through the 
naris. The posterior nares are then plugged. The external incision 
runs from just above the internal palpebral ligament below the line 
of the eyebrow for two thirds of the supraorbital margin. A peri- 
osteal flap is raised and a small disk of bone removed. This opening 
is then enlarged to permit satisfactory exposure of the sinus and 
access to the ethmoid cells. After all diseased tissue has been re- 
moved by curetting and a liberal passage into the nose established 
the cavity is swabbed with pure carbolic acid or chlorid of zinc, 
forty grains to one ounce, and packed with antiseptic gauze. No 
drain is carried into the nose, but the end of the gauze packing is 
brought out at the lower angle of the forehead wound, which is 
elsewhere carefully closed with sutures. If no signs of disturbance 
occur the gauze is left in place for three or four days when part of 
it is withdrawn and cut off. This is repeated every few days until 
all is removed and the cavity is lined with granulation tissue, when 
the wound is allowed to close. Eight out of fourteen cases thus 
treated were cured, in two pus discharge still continued, and in one 






THE ETHMOIDAL CELLS. 99 

a fatal result ensued from septic osteomyelitis attributed to imper- 
fect nasal drainage and too close stitching of the external wound. 
This cannot be regarded as a very flattering exhibit, although the 
cases were probably rather severe in type. 

The advantages of being able to dispense with packing and drains 
due to establishment of free communication between the nasal fossa 
and the sinus must be obvious. Better union of the external wound 
is thereby ensured and the risk of sepsis is reduced to a minimum. 

The question as to whether a radical external operation should 
be advised in a given case is not always easy to answer. By no 
means every case thus handled gets well, if by that we mean absolute 
cessation of pus discharge. On the other hand the appearance of 
pus in the middle meatus known to proceed from the frontal sinus is 
far from being an indication for immediate external operation. 
Continued difficulty in concentrating the mind, constant headache 
associated with frontal suppuration and more or less nasal obstruc- 
tion may be accepted as indications for radical interference, in case 
intranasal methods have already failed, and provided the patient is 
willing to submit to probable disfigurement and at the same time 
take the chance of incomplete relief. 



ETHMOID CELLS. 

The mania for classification of disease seems to have reached a 
climax in the case of the ethmoid cells. Almost every writer on 
the subject has his own arrangement of the morbid conditions affect- 
ing this region based either on a pathological hypothesis or on clin- 
ical history. Most of the former are more or less erroneous while 
the latter are apt to be confusingly elaborate. In view of the fre- 
quency of ethmoid disease it is rather surprising that such extreme 
difference of opinion should prevail as to its origin and nature. Bos- 
worth regards ethmoiditis as the most common form of sinus inflam- 
mation, while the post-mortem records of Lapalle show the occur- 
rence of ethmoidal empyema only six times, frontal five, sphenoidal 
nineteen and maxillary forty-eight times in fifty-five cases of sinus 
disease. In every instance empyema of other sinuses coexisted — 
the maxillary five times, the sphenoidal four times and the frontal 



L.cFC. 



IOO DISEASES OF THE NOSE AND THROAT. 

twice. An ethmoiditis may be latent, that is, it may be disclosed 
by no well-defined objective symptoms, or it may be attended by 
free pns discharge the source of which is obvious. It may be ob- 
scured by the concurrence of mucous polypi, not only in the nasal 
fossae but even within the cells, and by orbital abscess. The latter 
complication is certainly very infrequent in this country. The mid- 
dle turbinate bone may be in a state of bulbous or cystic expansion 
and all the ethmoid cells may be enormously distended, their bony 
walls very fragile and more or less carious. Spiculae of bone may 
be found in the discharges and the existence of necrosis may be 
determined by exploration with the probe or the finger. Empyema 
of the ethmoid cells seems to occur without regard to sex or age, 
except that most cases of orbital abscess have been reported in young 
subjects. 

The causative relations of ethmoiditis and of sinus disease in gen- 
eral to atrophic rhinitis, or " ozena " as some writers persist in call- 
ing it, a theory especially advocated by Griinwald, and to nasal 
polypi have been fertile topics of debate. Bresgen found empyema 
of the maxillary sinus or of the ethmoid cells in eleven cases of 
atrophic rhinitis, Moure in 32 out of 114 cases, while Jacques and 
George firmly maintain the causative relation of sinus disease to 
atrophy and assert that implication of the sphenoidal sinus and eth- 
moid cells most frequently preexists. The relation of sinus disease 
to nasal polypi will be discussed at length in the chapter relating to 
the latter. 

A rather rare condition of some interest but fortunately not of 
very serious import — emphysema of the eyelid — has recently been 
described by Beaman Douglass. It may occur as a result of dis- 
ease of the ethmoid cells or of injury to them in operating. As a 
consequence of violent blowing of the nose after a laceration of the 
lachrymal duct or of a compound fracture of the nasal bones it does 
not concern us in this connection. The upper lid rather than the 
lower is invaded, the air finding its way from the ethmoid cells 
through the wall of the orbit and forward along the fascia which 
separates the extrinsic muscles of the eyeball from the intrinsic. 
The accident is indicated by the occurrence of sharp pain in the 
orbital region, immediate swelling of the lid and more or less dis- 



THE ETHMOIDAL CELLS. IOI 

placement or protrusion of the eyeball. Usually the air is absorbed 
and the parts resume their normal appearance in a few days with 
the exception perhaps of some degree of ecchymosis. With a view 
to avoiding this accident the use of a small blunt-edged forceps in- 
stead of a curette in the ethmoid region is recommended as being 
less likely to perforate the lamina papyracea. The advice is also 
given, with seemingly less foundation, " never to amputate any part 
of the middle turbinate " as it constitutes an important guide to the 
ethmoid cells. In many cases it will be necessary to sacrifice the 
middle turbinate, or at least its anterior end, in order to gain suffi- 
cient operative space, and indeed by so doing we frequently immedi- 
ately enter the anterior ethmoid cells. 

Inflammation of the ethmoid cells may be catarrhal or suppura- 
tive. The former often accompanies an acute rhinitis and subsides 
as the latter disappears, or may degenerate into a purulent process. 

Suppuration of the ethmoid cells may be acute or chronic, the 
former owing to the anatomical construction of the parts tending 
to develop into the latter. In some cases the only symptom may be 
a discharge of pus from the nostril. If the anterior group of cells 
only, or the fronto-ethmoid cells, is affected pus appears in the mid- 
dle meatus ; if the posterior group is diseased pus is apt to spread 
over the septal surface of the middle turbinate body and to find its 
way backward to the nasopharynx. The tendency to spontaneous 
recovery is slight in ethmoid disease and in addition to the pus dis- 
charge we may have certain symptoms which are characteristic. 
Pain is usually deep seated and is frequently referred to the bridge 
of the nose or the postorbital region. Occasionally mixed with the 
pus bits of carious bone may be detected. When the bone is affected 
crepitation may sometimes be elicited by firm pressure at the inner 
angle of the orbit. Even in the absence of pus there may be a pecu- 
liar sickening odor, and when necrosis is in progress there is added 
the characteristic necrotic odor. There may be ocular disturbance, 
exophthalmos and contraction of the visual field from pressure upon 
the orbit, and where there is a great deal of intracellular mischief 
much distress may result from distention of the ethmoid cells and 
intranasal pressure. The sense of smell is more or less impaired. 
Indications of septic infection may be exhibited in febrile reaction 



102 DISEASES OF THE NOSE AND THROAT. 

and general systemic depression. In aggravated cases symptoms of 
meningitis may develop. In fortunate cases the pus is discharged 
into the nasal chamber; in others, it may open at the inner angle of 
the orbit. It may reach the antrum or frontal sinus or, in its worst 
phase, it may penetrate the anterior cerebral fossa and induce a fatal 
meningitis. 

A diagnosis must often be reached by exclusion. In cases in which 
the foregoing symptoms are pronounced there should be no difficulty 
in defining the condition ; but in others the symptoms may be so 
obscure as to leave the case a long time in doubt. 

A serious prognosis must be given unless free intranasal drainage 
is established. And even then while pus formation is active the 
patient is not absolutely out of danger. Kuhnt has recorded seven- 
teen cases of fatal meningitis consecutive to sinus disease. 

Treatment, in cases of moderate severity, consists in free opening 
of the ethmoid cells through the nostril by means of cutting forceps, 
drill or curette and the subsequent thorough cleansing of the parts 
with an antiseptic solution (Fig. 45). A nasal deformity which in- 
terferes with drainage should be corrected. The possibility of other 
sinuses being involved should not be overlooked. Complication of 
the case by the existence of nasal polyps is very frequent and they, 
as well as excessive granulation tissue and necrotic bone, should be 
removed. These operative procedures upon the ethmoid may be 
done under local anethesia with cocaine. Careful examination with 
the probe for the detection of spiculse of bone should be practiced 
and the case should be kept under close watch so long as suppura- 
tion continues. 

The anterior ethmoidal cells are situated in the upper part of the 
ethmoid and fill in the floor of the frontal sinus. Most of them are 
large and many have their walls completed by articulation with 
neighboring bones. They are very numerous and suppuration in- 
volving them is liable to be transmitted to the frontal sinus. 

Such being the case the operation which has just been described 
is applicable only to disease limited in extent and in an unusually 
wide nasal chamber. In some cases of long standing nearly all the 
ethmoid cells are involved more or less and a very large portion of 
them are quite inaccessible through the nasal fossa. In attempting 









THE ETHMOIDAL CELLS. 



IO3 



to curette the field of operation is almost immediately obscured by 
hemorrhage, so that we run the risk of carrying our instrument in 
an improper direction or too far, thus either invading the orbital 
cavity or possibly perforating the cribriform plate and entering the 




Fig. 45. a, Hajek's double curette ; b, c, Grunwald's cutting forceps. 

cerebral fossa itself. About all that can be done by the nasal method 
of treating ethrhoiditis is to remove the middle turbinate including 
the cell which sometimes exists in its body and enrette the cells in 
its immediate neighborhood. When relief is not obtained by this 
means an external operation is the only sate and radical mode of 
treatment. An external incision along the inner angle of the orbital 



104 DISEASES OF THE NOSE AND THROAT. 

ridge at about the level of that practiced for opening the frontal 
sinus is recommended. By this incision the frontal sinus is exposed 
with its floor and the ethmoidal region is brought within easy reach. 
All the cells can be thoroughly curetted and an opening made into 
the nasal cavity for drainage, so large that no drainage tube is re- 
quired. If necessary the posterior group of cells may also be at- 
tacked by this route. The external wound, after thorough cleansing 
and sterilizing of the cavity, is closed as in the operation for frontal 
sinus disease. Usually the wound heals without much disfigure- 
ment, provided it be carefully sutured and nasal drainage be ade- 
quate. Care should be taken in irrigating the nasal fossa to use no 
violence in order that the wound may not be disturbed. 

The more formidable operation just described is called for very 
exceptionally. In the majority of cases the patient will be content 
with the relief given by opening and draining the cells through the 
nose, even though the disease cannot be thus completely obliterated. 



SPHENOIDAL SINUS. 

Inflammation of the sphenoidal sinus is probably less rare than 
has been hitherto supposed. It is of rather serious nature since it 
exhibits but slight tendency to resolve and is disposed to affect the 
periosteum and bone. The causes acting to produce disease here 
are similar to those that prevail with reference to the other sinuses, 
and the pathological changes resemble those occurring elsewhere. 
The opening of the sphenoidal sinus is so situated as to impede the 
free escape of secretion. It may sometimes be found by passing a 
probe obliquely upwards across the middle turbinate body and close 
to the septum (Fig. 46). The pus secreted in sphenoidal sinusitis 
usually flows backwards into the pharynx. No doubt many cases 
of so-called postnasal catarrh are really examples of sphenoidal in- 
flammation. The pain is of an aching character and may be intense 
and radiating. Ocular symptoms are very apt to develop in sphe- 
noidal disease, from involvement of the trigeminus. Impairment or 
loss of sight and exophthalmos have been observed. In a case 
under my own care marked ptosis was a prominent symptom which 
disappeared as the inflammatory signs subsided. It is seldom pos- 



THE SPHENOIDAL SINUS. IO5 

sible by rhinoscopy, either anterior or posterior, to determine defi- 
nitely the origin of the pus ; that is, it can not be seen actually flow- 




Fig. 46. Probe in Orifice of Sphenoidal Sinus Showing Distance from 
Nasal Vestibule, about 2^/2 inches. {Bryan.) 
Sieur and Jacob profess to be able to catheterize the sphenoidal ostium by 
passing a curved instrument close to the dorsum of the nose and the under 
surface of the cribriform plate, instead of going obliquely across the middle 
turbinate. 

ing from the sinus. In general pus from the sphenoidal sinus in- 
clines to spread out over the vault of the pharynx. It may be im- 



106 DISEASES OF THE NOSE AND THROAT. 

possible to tell whether the discharge comes from the sphenoidal 
sinus or the pharyngeal bursa, suppuration of which, under the name 
of Tornwaldt's disease, is occasionally observed. 

The prognosis in sphenoidal sinusitis is less favorable than that 
of inflammation of other sinuses owing to the difficulty of reaching 
the cavity. Extension of the disease to the orbit or meninges may 
occur with fatal results. A case of erosion of the cavernous sinus 
with fatal hemorrhage has been reported and others of thrombosis 
involving the circular and cavernous sinuses and the ophthalmic 
veins have been recorded. An extraordinary case in which the 
whole body of the sphenoid was extruded, the patient recovering, 
was reported many years ago by Baratoux. 

In the treatment of sphenoidal sinusitis the most important indi- 
cation is early and free opening so as to permit the removal of 
necrosed bone, if any exists, and thorough drainage of the cavity. 
The drill or trocar is introduced in the direction indicated for dis- 
covering the anatomical outlet of the cavity, namely, obliquely up- 
wards across the middle turbinate body. The distance of the ante- 
rior wall from the tip of the nose in the adult varies from three to 
three and three fourth inches ; the average depth of the sinus is 
about a half inch, but the investigations of Onodi and many others 
have shown irregularities to be so frequent that these measurements 
must not be accepted as absolutely reliable. When drainage is once 
well established and the parts kept aseptic by thorough cleansing, 
recovery may be expected. 

In an elaborate study of the sphenoid by Beaman Douglass at- 
tention is directed to the existence in the smaller sphenoidal wings 
of supplementary cells originally described by Zuckerkandl and 
Hajek. Their surgical importance is considerable in connection 
with an inflammation involving either the sphenoidal sinus or the 
posterior ethmoidal cells. In some cases the main sphenoidal sinus 
has been found to extend partly or completely into the wing of the 
bone. In others the sinus in the wing is quite independent and 
opens by its own passage into a posterior ethmoidal cell or into the 
recessus spheno-ethmoidalis. In still other cases a posterior eth- 
moid cell is prolonged into the wing of the sphenoid. The relations 
of these sinuses are described as follows. Above a mere shell of 



THE SPHENOIDAL SINUS. I QJ 

bone separates them from the optic nerve and chiasm and the brain 
itself. The nasal fossa and the anterior part of the great sphenoidal 
sinus form their floor. In front lie the posterior ethmoidal cells, 
while along the outer wall runs the optic nerve, and if the sinus is 
of large size the carotid artery and the Vidian nerve may be found 
in close proximity. The wall of the orbit may be formed in part 
by that of the sinus. Obviously distention of the sinus by pus or 
absorption of its contents may create disturbance in contiguous 
structures, while the risk of damage to the latter in operating is a 
serious possibility. The existence of this anomaly thus adds not a 
little to the difficulty of diagnosis and the complications of operative 
interference. Yet it is claimed that in some cases it may be easier 
to enter the sphenoidal sinus by cutting away the posterior ethmoidal 
cells and through the smaller wing than by the route usually fol- 
lowed in the vicinity of its normal opening. 

The plan of gaining access to the sphenoidal by way of the max- 
illary sinus, first suggested by Jansen, has recently been advocated 
by Furet. He especially advises it in those rare cases of sinusitis 
with cerebral complication, in which a rapid and thorough operation 
must be done, also in cases in which an antral empyema coexists, 
as well as in those in which the maxillary sinus is not involved, but 
the nasal route cannot be followed owing to atresia or deformity of 
the nasal fossae. 

The idea of approaching the sphenoidal sinus through the mouth 
and pharynx, which has been proposed, seems to be a very blind and 
dangerous procedure. The proportion of cases in which the sphe- 
noid cannot be reached through the nasal passages, if necessary after 
a preliminary removal of obstructions, must be extremely small. 

The particular method of opening the sinus is less important than 
that the aperture should be ample and as near as possible to the floor 
of the cavity. Spiess prefers to puncture the anterior wall by means 
of a trephine propelled by electricity. Hajek tears down the ante- 
rior wall with a hook passed through the sphenoidal orifice, while 
Griinwald, after having enlarged the opening with a sharp spoon, 
breaks off portions of the bony wall in a downward direction with 
his punch forceps. If on exposure of the cavity it seems to be nec- 
essary to curette its walls the greatest caution should be observed 



I08 DISEASES OF THE NOSE AND THROAT. 

in the region of its roof, where the thin plate of bone might readily 
be penetrated with most disastrous results. Free drainage, removal 
of all diseased tissue, followed by swabbing the cavity with pure 
carbolic acid and occasional antiseptic irrigations subsequently are 
said to bring most of these cases to a successful termination in the 
course of a few weeks. The risk of hemorrhage in opening the 
sphenoid is much increased by the proximity of the cavernous sinus 
and of the internal maxillary artery. From the latter a branch 
passing through the spheno-palatine foramen sends a small twig 
across the anterior face of the sphenoid to supply the mucous mem- 
brane of the nasal septum. In a case reported by Hinkel a very 
severe hemorrhage occurring on the tenth day is believed to have 
had its source in the sphenopalatine artery. Several similar cases 
of bleeding, primary as well as secondary, are on record in which 
the flow was arrested by the use of a firm tampon. The difficulty 
of diagnosis and the danger of surgical interference are thus seen 
to be much greater in the case of the sphenoidal than of the other 
accessory- sinuses. 



HYDROPS ANTRI. MUCOCELE AXD CYST. POLYPI. 
FOREIGN BODIES AXD NEOPLASMS. 

The ancient term hydrops antri is deemed inconsistent with mod- 
ern ideas of pathology. It seems to be quite certain that a serous 
or muco-serous effusion may take place into a sinus cavity in the 
congestive stage of an inflammatory process which never advances 
to suppuration. For such a condition the term mucocele is appro- 
priate. In a very remarkable case recorded by H. Luc the "frontal 
and maxillary sinuses of the same side were affected by mucocele 
without discoverable cause, the disease being cured by the usual 
operation performed for empyema of these cavities. He refers to 
a similar case reported by Laurens in which the duct from the 
affected sinuses was occluded by an enormous osteoma. It is not 
improbable that a mucoid collection may occur in a sinus more often 
than is generally supposed, since a non-inflammatory process of 
this kind is attended by so few subjective symptoms. It is possible 
that an escape of fluid into the antrum may occur in the course of a 



CYST OF THE MAXILLARY SINUS. 1 09 

general dropsy. But these cases are extremely rare. An accumu- 
lation of non-purulent fluid in a sinus cavity may be in most cases 
properly called a cyst, the walls of the sinus forming its boundaries, 
in consequence of disappearance of its original limiting membrane 
by distention, rupture and absorption. In cases of long standing 
this is likely to be the course of events, whether the process has its 
inception in a lymph space or in the acinus or duct of a gland, or 
begins as a dentary cyst, for the reason that its early symptoms are 
very ill-defined. Hence an actual cyst wall is seldom seen. It is 
suspected that some cases of alleged nasal hydrorrhea are of this 
kind. The antrum of Highmore is the most frequent seat of this 
phenomenon. When the ostium maxillare becomes blocked from 
any cause and the secretion causes distention, more or less pain or 
swelling may call attention to its existence. In time the anterior 
wall of the sinus becomes so thin that characteristic crepitation on 
palpation may be detected. In the case referred to in discussing the 
diagnosis of empyema of the antrum the contrary was true and it 
was supposed that we had to deal with a solid tumor, until its charac- 
ter was demonstrated by the light test. The quality of the effusion 
is usually such as to offer no obstacle to transillumination. In a 
case detailed by Fergusson exploratory puncture showed the nature 
of a tumor previously supposed to be solid, while Heath refers to a 
case within his own knowledge in which the upper jaw was removed 
before the error in diagnosis was discovered. The quantity of fluid 
varies from a drachm or two to several ounces. It is colorless or 
faintly straw colored and may be clear or slightly turbid. Choles- 
terin is usually found in abundance. Occasionally the fluid is quite 
dark or even greenish and in a case recorded by Maisonneuve it 
presented a buttery consistency. The researches of W. Adams, fol- 
lowed by Giraldes, seem to show that cysts beginning in the glandu- 
lar follicles of the mucous membrane may be single or multiple and 
may easily escape detection in the ordinary way of tapping the 
antrum. In general mere evacuation of the fluid effects a cure. If 
the cysts are very numerous it may be necessary to curette the wall 
of the antrum and afterward use astringent irrigations. It is wise 
to open the cavity freely in order that bony septa or foreign bodies 
may not be overlooked. The inconvenience to the patient result- 



I IO DISEASES OF THE NOSE AND THROAT. 

ing from such a course is insignificant, while its advantage over 
simple aspiration must be apparent. 

Polypi may develop in the lining membrane of a sinus and un- 
dergo cystic degeneration precisely as they sometimes do in the 
nasal chambers. Or their presence may excite a profuse watery 
secretion which escapes by way of the nasal fossae and is mistaken 
for a nasal hydrorrhea. Spencer Watson quotes an interesting case 
of this kind observed by Paget in which the actual condition was 
demonstrated by post-mortem inspection. Until symptoms due to 
pressure or distention appear it may be impossible to offer a diag- 
nosis without a free opening of the sinus. Watson calls attention 
to certain extraordinary cases of cyst of the antrum associated with 
optic neuritis and nerve atrophy. It would seem that some of the 
cases included by him in this category, in which symptoms of cere- 
bral disturbance were exhibited, might to-day be regarded as in- 
stances of escape of cerebrospinal fluid, a condition to be referred 
to in the chapter on nasal neuroses. Intranasal polyps often coexist 
and it is by no means unreasonable to suppose that a condition favor- 
ing the development of the former may extend to the mucous mem- 
brane lining the accessory sinuses. This especially applies to the 
ethmoid cells, which are almost invariably found in a state of poly- 
poid degeneration in inveterate cases of nasal polyp. Nasal sup- 
puration is not proportionate to the degree of sinus disease. It has 
several times been my experience to open an antrum or a frontal 
sinus and find extensive degeneration of its mucous lining with 
scanty pus accumulation. The discharge is sometimes slightly of- 
fensive, a fact perceptible to the patient if his sense of smell is 
preserved. Heath declares that polypi of the antrum are very vas- 
cular, a fact undoubtedly true of malignant disease but less admissi- 
ble regarding simple gelatinous polypi. In fact excessive hemor- 
rhage from a tumor connected with the nasal passages must always 
be looked upon as a danger signal. Simple mucous polypi are not 
vascular and spontaneous hemorrhage is very unusual. A polyp 
attached within the antrum has been known to protrude into the 
adjacent nasal fossa, but as a rule sinus polypi are small and multi- 
ple. The proper treatment for a case of this kind is to thoroughly 
open the sinus and curette every part of the affected mucous mem- 
brane. 



FOREIGN BODIES IN A SINUS. I I I 

Foreign bodies are occasionally found in a sinus, especially the 
maxillary. Missies from firearms, teeth erupted in the wrong direc- 
tion or driven into the cavity in attempts at extraction, lost drain- 
age tubes used in treating a sinus empyema are among the most 
common. In certain countries animal parasites are not infrequently 
discovered in these cavities, where they often cause extreme distur- 
bance and sometimes extensive destruction of tissue. A diagnosis is 
difficult unless the larvae are found in the nasal discharges. A for- 
eign body may be retained a long time without giving any positive 
indication of its presence. In a case recently reported by Lohnberg 
a piece of metal was exposed in the ethmoid cells after removal of 
a large number of nasal polyps. Twenty years before this patient 
had lost an eye by explosion of a gun and unquestionably the piece 
of metal had at that time penetrated the orbital wall and become 
lodged in the ethmoid region. In a second case the patient was 
hit on the forehead with a wrench, a fragment of felt being torn 
from his hat and driven into the frontal sinus. It excited a chronic 
suppuration for which an operation was undertaken and the foreign 
body was thus discovered. Heath refers to a case in which a knife 
blade was lodged in the antrum for forty-two years and was finally 
expelled from the nostril, and describes another remarkable case in 
which a gun breech found its way into the throat after having re- 
mained twenty-one years in the antrum. 

Neoplasms, either benign or malignant, may be met with in a 
sinus, having originated there or having invaded it from adjacent 
parts. The latter is far more frequent, at least as regards malig- 
nant disease. In this situation a benign tumor, although less acces- 
sible, is operable as elsewhere, but the question of a malignant ten- 
dency or perhaps a mixed character, especially at certain periods of 
life, has always to be answered. Malignant disease involving the 
antrum and more rarely the other accessory sinuses has generally 
been regarded as a desperate condition. It may assume the type of 
sarcoma or epithelioma and is so insidious and rapid in its develop- 
ment that in most cases it is beyond reach by the time its character 
is made known. The age and condition of these patients generally 
preclude extensive surgical operations, so that many snrgeons pre- 
fer to attempt destruction of the growth by the actual cautery and 



I I 2 DISEASES OF THE NOSE AND THROAT. 

escharotics. Malignancy here is no exception to the law applicable 
to it elsewhere, namely, that it is curable by the knife, provided all 
of the disease and every infected lymph channel and gland be extir- 
pated. The difficulty is to define accurately the limits of disease. 
So-called recurrence means a failure to accomplish this end at the 
original operation. Those who realize what it is to face the agonies 
of slow death from an eroding cancer may prefer to take the 
chances of surgery even though most unpromising. 

In a series of cases of malignant disease of the nose and accessory 
sinuses collected by J. S. Gibb are found five of carcinoma and three 
of sarcoma primary in the antrum or other sinuses. In three of the 
former death from recurrence took place (Dombrowski, Bolan-2) 
of one, in which an excision of the uper jaw was done, no subse- 
quent history is given (Bolan), and in the fifth, in which the antrum 
was curetted through the alveolus, there had been no return after 
fourteen months (W. C. Phillips). Of the cases of sarcoma two 
had recurrence and died (R. Levy, S. M. Burnett) and one, a case 
of osteosarcoma, in which the upper jaw, the turbinates, the palate, 
the vomer and parts of the ethmoid and malar bone were removed, 
had no recurrence eight years later. No doubt many cases have not 
been put on record. In this connection a remarkable case of suc- 
cess with Coley's toxin treatment in a spindle-cell sarcoma of the 
upper jaw is of interest. An attempt had been made to remove the 
tumor by an excision of the upper jaw, but failed and the growth 
rapidly increased in size. A few injections of the toxins of erysipe- 
las and the bacillus prodigiosus were made in the tumor and after- 
wards all were made in the abdominal wall. Although the actual 
condition of the affected parts is not stated, Coley declares that " the 
patient practically recovered and resumed his occupation." As an 
evidence of improved nutrition an increase of thirty pounds in 
weight while under treatment is noted. Some skepticism might be 
permitted as to the diagnosis in this case, but for the fact that the 
verdict rests not only on the clinical symptoms but also on micro- 
scopical examination by an expert. While much of the testimony 
regarding the toxins is negative or distinctly unfavorable, their use 
is certainly justifiable in cases of recurrent sarcoma or in those 
decided to be inoperable. 



MALIGNANT DISEASE OF A SINUS. II3 

From a study of this subject by Schwenn suppuration, fetor, rapid 
extension and recurrence would seem to be the main characteristics 
of malignant disease of a sinus. Pain also is almost invariably 
present and may be intermittent and neuralgic from compression of 
a nerve trunk or continuous from distention of the walls of the 
affected cavity. The tendency of malignant disease of the antrum 
to perforate at several points on the cheek or into the orbit is ob- 
served. Perforation may occur in simple empyema but only at one 
situation and only in case drainage is absolutely cut off. Ocular 
symptoms are prominent when the anterior ethmoid cells are in- 
volved. It may be difficult to determine whether displacement of 
the eyeball, disturbance of the lachrymal apparatus, or other eye 
symptoms are due to trouble originating within the orbit or in the 
ethmoid cells, especially when there is no nasal obstruction and no 
visible tumor in the nasal fossa. In most cases there is more or 
less obstruction of one nostril and in nearly every case the septum 
is attacked. Nasal breathing may not be much impeded. On the 
contrary when the disease springs from the posterior ethmoid cells 
the growth projects into the nasopharynx and obstructs the passages. 
In the latter case also the orbit is almost always invaded with involve- 
ment first of the sixth and then of the optic nerve and correspond- 
ing ocular disturbance. Tumors of the sphenoidal sinus cause a 
great variety of symptoms, impairment of hearing, of vision, of 
smell, of taste, trigeminal neuralgia, ill-defined headaches and finally 
cerebral symptoms. Their growth is usually very rapid, and the 
success of radical interference is extremely remote. 



CHAPTER S£" 

DISEASES AND DEFORMITIES OF THE NASAL SEPTUM. DEVIATION. 

ECCHONDROSIS. EXOSTOSIS. ULCERATION. PERFORATION. 

HEMATOMA. ABSCESS. CONGENITAL OCCLUSION OF THE 

NARIS. ADHESIONS. COLLAPSE OF THE NOSTRIL. 

DISLOCATION OF THE COLUMNAR CARTILAGE. 

FRACTURE OF THE NOSE. 

DEVIATIONS OF THE SEPTUM. 

The etiology of deviated septum has been the subject of much 
controversy. It is met with very early in life and has been pro- 
nounced congenital in certain cases. It is doubtful whether syphilis 
is a factor in its causation, but many cases exhibit more or less evi- 
dence of scrofulous taint. In a certain proportion of cases we suc- 
ceed in getting a history of traumatism and, when we consider how 
exposed the nose is to external injury and how much of the time is 
spent upon this organ in babyhood, we realize that the condition may 
be induced by frequent repetitions of mild degrees of violence, as 
well as by a single severe injury. 

The attempt has been made to classify deviations of the septum 
in accordance with the forms they assume, but the variations are so 
unlimited that a strict classification is not feasible and is clinically 
valueless. 

In general we may speak of horizontal, vertical and sigmoid devi- 
ations. In the first the long axis of the deformity is anteropos- 
terior, in the second it is at or near a right angle to the floor of the 
nose, and in the last the septum is seen to bulge into one nostril 
above and to the opposite side at its lower part, thus assuming a 
sigmoid or S form. In some cases the bowing of the cartilage is 
gradual and symmetrical, in others there is a narrow deep furrow 
on one side and a corresponding sharp prominence on the other, as 
if the septum in its plastic state had been compressed in its vertical 
plane, or, as Lennox Browne puts it, "a crumpled partition " exists. 

114 



DEVIATIONS OF THE NASAL SEPTUM. I I 5 

The first is by far the most frequent form and the second the rarest. 
Sigmoid deviations are quite common and are perhaps the most dif- 
ficult to deal with. One of the most intractable deformities of the 
septum is that in which an anterior deflection of the cartilage is asso- 
ciated with a displacement of the bony septum into the opposite 
naris, constituting what may be called a horizontal sigmoid devia- 
tion. Opinions differ as to whether excessive height of the palatal 
arch almost always seen in connection with a deviated septum bears 
a relation of cause or effect. The concurrence of adenoids with 
septal deflection and a high narrow hard palate, especially in young 
subjects who are mouth-breathers, is a matter of common observa- 
tion. It is probable that the same diathetic state is concerned in 
the etiology of each of these conditions. The fact that deviations 
of the septum are seldom seen in early life, with a history of 
injury, would enforce the theory that most of these cases are due 
to arrest of palatal development, or overgrowth of septal tissue, or 
both combined. In early fetal life the hard palate is above the level 
of the Eustachian tubes and gradually descends in process of normal 
development. The Gothic arched palate must be looked upon as a 
frequent result of the maldevelopment often associated with adenoids 
in the rhinopharynx and consequently as one of the causes of septal 
deformity. Mayo Collier contends that deflections occur at the 
thinnest and weakest part of the septum, in consequence of relatively 
increased atmospheric pressure due to rarefaction of air on inspira- 
tion, which latter results from some form of obstruction in the nos- 
tril. This certainly cannot be regarded as a satisfactory explanation 
of all varieties of deviation. 

In the majority of cases the cartilaginous septum is chiefly af- 
fected ; no matter how great a bending may exist in the anterior part 
we find the posterior margin of the vomer maintaining a vertical 
position. Hence there is always a sacrifice of breathing space, the 
wider nostril admitting no more air than its narrowest portion allows 
to pass. The simplest form of deviation is that consisting of a bow- 
ing of the cartilage, one side being concave, the other convex, with- 
out marked thickening. Associated with the deflection more or less 
enlargement of the inferior turbinate body opposite the concavity of 
the septum is likely to exist as a result of nature's effort to prevent 



Il6 DISEASES OF THE NOSE AND THROAT. 

the admission of an undue volume of air. The hypertrophy, there- 
fore, is a result, not a cause, of the deviation, though the latter may 
appear to be the case at first glance. 

The frequency of deviation is remarkable; an absolutely straight 
septum is almost unknown. Inspection of a very large number of 
skulls in various museums has shown that distortion of the bony 
septum is present in much more than half of the cases examined. It 
is reasonable to infer that deformities of the cartilage are far more 
frequent. Associated with the deviation, in a large proportion of 
cases, there is more or less thickening of the septum, especially at 
the apex of the bend in the form of ecchondrosis, or hyperchondro- 
sis, and over the vomer, exostosis. A thickening is also particularly 
observable along the junction of the quadrilateral cartilage with the 
vomer and the perpendicular plate of the ethmoid. Its preponder- 
ance along sutural lines gives credibility to the traumatic theory of 
causation, an arthritis being excited by a blow or fall which results 
in piling up of tissue along the lines of articulation. In other cases, 
however, where there is an absence of thickening, which would seem 
to be of inflammatory origin, the impression is given that the bend- 
ing is a result of overgrowth, or hypernutrition, the development of 
the septum continuing after the bones of the face have undergone 
consolidation, so that there is insufficient room in the vertical line 
for its accommodation. 

The symptoms induced by a deviated septum are those referable 
chiefly to nasal stenosis. In cases of extreme displacement, there 
may be some deformity of the external nose, the tip being tilted or 
twisted from the median line. Not infrequently the symmetry of 
the nostrils is impaired, or the columna nasi may be displaced. The 
effects of nasal stenosis are displayed, to a considerable degree, in 
the region immediately behind an obstruction and in the lower air 
tract as well. In no small proportion of cases laryngeal symptoms 
may be distinctly traceable to a deviated septum, and a condition of 
congestion in the postnasal space may involve the Eustachian tubes 
and lead to a train of annoying ear symptoms. Behind the stenosed 
area, the air being rarefied with each inspiration, a condition of 
chronic congestion is induced in the mucous membrane which event- 
ually leads to hypernutrition and hyperplasia. In case of complete 



DEVIATIONS OF THE NASAL SEPTUM. \\J 

stenosis, the functions of the nostril are entirely abolished. The 
impediment to inspiration is still further aggravated by collapse of 
the nostril on the affected side in consequence of the increased 
rapidity of the entering current of air, or weakness of the alar mus- 
cles. The effect upon the voice of stenosis due to septal deviation 
is often very marked; the quality and tone are impaired both from 
the abolition of the resonating chamber and from the associated 
catarrhal condition; in consequence, increased phonatory effort is 
likely to result in voice strain. In addition, we may have developed 
a train of reflex nerve symptoms to be elsewhere considered when 
the deviation is so exaggerated as to cause pressure upon a turbinate 
body. 

The diagnosis of deviation is not difficult if one takes pains to 
compare the nostrils and to explore the nasal fossse by means of a 
probe, with the finger tip, or, if need be, with a septometer. (See 
Fig. 10.) 

The prognosis under the present method of managing these cases 
is good so far as the lesion itself is concerned. As regards compli- 
cating disorders the outlook will depend in great measure upon the 
duration of the condition. In nearly every case we shall succeed in 
giving a certain amount of amelioration, if not complete cure, which 
will be permanent provided corrective measures are not undertaken 
too early in life. 

The only treatment for the condition is surgical. The earliest 
attempts to correct the deformity consisted in pressure upon the dis- 
placed cartilage by means of the finger repeated by the patient him- 
self at short intervals. Various plastic operations have been recom- 
mended in which the mucous membrane is dissected up and redund- 
ant portions of the deflected cartilage excised, the soft parts being 
subsequently replaced or brought together by means of sutures. 
More elaborate operations consist in raising the tip of the nose by 
external incision or by the incision of Rouge, so as to allow free 
admission to the nasal cavities. Among the early operative re- 
sources, for a long time popular, was that known as the method of 
Blandin, which consisted in the removal of one or more segments of 
cartilage by means of a punch, no effort being made to save the 
mucous membrane. Of course, this resulted in permanent perfora- 



:8 



DISEASES OF THE NOSE AND THROAT. 



tion of the septum. For many years what is known as Adams' 
operation was practiced, in which the septum was seized with forceps 
and was fractured in such a way as to permit its replacement in the 
middle line (Fig. 47). The broken septum was retained in proper 
position by inserting ivory plugs which were worn until firm union. 
The results of this operation have been more or less disappointing 




for the reason, in the first place, that the shape of the deformity 
varies so much in different cases that no one method is applicable to 
all. In addition, great thickening at the apex or convexity of the 
deformity may be often more important than the deflection itself. 
In not a few instances simple removal of the overgrowth of tissue 
on the convex side will restore the air current sufficiently so that any 
attack upon the septum beyond this is found to be unnecessary. In 



Q K 



7 



:: 



9 



Fig. 48. Nasal Drills, Trephi 



;d Burrs. 



many cases removal of the thickened portion with a saw will answer 
every purpose. In others where the thickening does not constitute 
an abrupt spur or ridge, the drill, or nasal trephine of Holbrook 
Curtis (Fig. 48) will be found to give better satisfaction. The tre- 
phine may be passed at several levels or the projecting shoulders 
left above and below its track may be smoothed off with rongeur 



DEVIATIONS OF THE NASAL SEPTUM. U9 

forceps. The drill and trephine are most conveniently operated by 
the electro-motor, and the saw also may be used with electric power, 
but the handsaw is rather more manageable and safer. It may be 
necessary to reduce a swollen turbinate before attempting to replace 
a bent septum. All these minor, or preliminary operations may be 
done under cocaine anesthesia. But few would be able to endure the 
pain involved in fracturing and readjusting the septum itself with- 
out a general anesthetic. For cases of simple deflection without 
thickening the pin operation of Roberts occasionally gives good re- 
sults. In this operation an incision is made along the prominence of 
the deflection with a bistoury, the parts are then pushed over into 
position, where they are held by means of a long steel pin passed 
through the columna from the concave side across the line of incision 
and into the septal tissues above and behind. The head of the pin 




Fig. 49. Steele's Septum Punch. 

protrudes from the nostril, or may be concealed in the vestibule, and 
does not interfere with breathing; it should remain in place a week 
or longer until the replaced septal fragments have become consoli- 
dated. More than one pin may be required to- give proper support. 
It is important that the cartilage should be thoroughly loosened in 
order to obviate undue pressure from the shaft of the pin ; other- 
wise there is danger of its cutting its way through the tissues. The 
obvious advantage of this method, where applicable, is that nasal 
breathing is not interfered with. An attempt to remedy the defor- 
mity by multiple incisions, or by stellate incisions with a forceps 
like that devised by Steele (Fig. 49) and modified by Sajous and 
others, has been only moderately successful. Roe prefers to break 
the septum without lacerating the soft parts, and for this purpose 
uses a special forceps, one blade of which is larger than the other 
and fenestrated (Fig. 50). The blades are made of different sizes 
and may be adjustable to a common handle. In operating the solid 
or male blade is inserted in the convex side and the ring blade in the 



120 DISEASES OF THE NOSE AND THROAT. 

opposite nostril. The solid blade fits the ring- loosely, and when the 
instrument is closed other portions of the septum than that immedi- 
ately compressed are not disturbed. The importance of fracturing 
the bony septum in most cases is insisted upon, and it is claimed that 
it may be done with this instrument without any of the risks inci- 
dent to the twisting and rocking motions necessary with other septal 
forceps. In many cases the comminution of the septum accom- 
plished by Roe's forceps does not wholly overcome the redundancy 
of tissue which must be provided for by preliminary incisions of the 
cartilage. These incisions should be made oblique, or beveled, so as 
to permit the fragments to override each other. Thus the thick 
ridges formed when the septum has been straightened after cuts at a 
right angle to its vertical plane are in large part avoided. If the 




Fig. so. Roe's Septum Forceps. 



cartilage is not excessively redundant these incisions may be made 
from the concave side only to the perichondrium of the convex side, 
the finger in the latter nostril readily guiding the knife. Usually 
two incisions, a horizontal and a vertical one, crossing at the point 
of greatest deformity are required, and a special cartilage knife with 
a shield which may be used to limit the depth of the cut is recom- 
mended. Turbinate hypertrophies, adhesions and so far as possible 
ridges and spurs of the septum should be removed before attempts 
at straightening are undertaken. A ridge projecting from the inter- 
maxillary bone in the floor of the nose often present in these cases 
may sometimes be broken with the forceps, but not infrequently a saw 
or chisel may be needed if the bone is very dense. For holding the 
septum in right position a metal plate wound with cotton or gauze 
to the proper size is preferred to any other mechanical appliance as 
well as to the tubes in common use. It is left in place for three or 
four days, then removed, the parts cleansed with a warm borated 
bichlorid solution, i to 5,000, and a fresh plug inserted for two days, 



DEVIATIONS OF THE NASAL SEPTUM. 



121 



by which time the septum is usually firm in its corrected position. 
Any tendency to recurrence of deformity may be arrested by the 
introduction of a non-perforated hard rubber or aluminum tube for 
a few days. The preliminary work is done with cocaine and supra- 
renal extract; the actual fracturing under primary chloroform anes- 
thesia. 

A mode of operating recently suggested by E. J. Moure presents 
several interesting features and is claimed by its promotor to have 
certain advantages over the Ascli operation presently to be described. 
He evidently misconceives some of the details of the latter operation 
as practiced at present, especially as regards the management of the 




Fig. si. Moure's Osteotome. 



tube. Three stages of Moure's operation are outlined as applicable 
to the majority of cases, but of course not all, since the three condi- 
tions to be met are not always found. In the first place a ridge of 
cartilage, or ecchondrosis, at the apex of the deviation is removed 
with an elliptical ring osteotome (Fig. 51). In the second place 
the anteroinferior border of the cartilage, which is often luxated into 
the nostril opposite the convexity of the deviation, is shaved off with 
a bistoury, after having been button-holed by an incision along its 
most prominent part. Finally after these wounds have healed, that 
is, in the course of a month, the deviation itself is attacked. The 
direction of the incisions and the intranasal s]>linl used lor supporting 



122 DISEASES OF THE NOSE AND THROAT. 

the septal fragments differ from those in other operations. The cuts 
are made with scissors, almost identical with those of Asch, the first 
one nearly parallel with the floor of the nose and as close as possible 
to the inferior attachment of the cartilage (Fig. 52). A second cut 




n Moure's Operation. 



is made obliquely upward and as close as possible to the dorsum of 
the nose, leaving a somewhat narrow bridge of cartilage between the 
anterior ends and a very wide one between the posterior ends of 
the incisions. This triangular movable fragment of cartilage is 
held in front at the tip of the nose by a band of cartilage and behind 
by the perpendicular plate of the ethmoid and the vomer. A special 



Fig. S3- Moure's Nasal Tube and Dilating Forceps. 

tube, composed of two parallel blades, the outer one rigid to rest 
upon the turbinate, the inner one malleable, is then introduced. The 
malleable blade is then moulded against the deviated cartilage, thus 
correcting the deflection to the desired degree, by means of dilating 
forceps passed into the tube (Fig. 53). The tubes, which are made 



DEVIATIONS OF THE NASAL SEPTUM. 



123 



in pairs, one for either nostril, are left in situ for at least eight days, 
a single tube being used only on the convex side in a given case. 
This method of operating is said to be rapid and not attended by 
much hemorrhage. Local anesthesia with cocaine is all sufficient, 
pain, if any, being due to the tube rather than the operation itself. 
No local treatment is advised, unless there is a good deal of purulent 




Fig. 54. Kyle's Operation for Deflected Septum by Removal of V-shaped 
Segments. 
a and b show the location of incisions and the position assumed by the septum 
after the removal of the wedge-shaped pieces. 

secretion, in which case the nasal fossze may be douched twice a 
day with warm boracic acid solution, and the same may be applied 
externally for the relief of pain. Uniformly good results are claimed 
for this method of operating at least in adults. It is considered 
unwise to touch the septum until development is complete, that is, 
not before the sixteenth year. 

In the operation described by Braden Kyle a V-shaped wedge of 
muco-chondrial tissue is resected antero-posterinrlv, tin- base of the 



I 24 DISEASES OF THE NOSE AND THROAT. 

wedge looking toward the convexity and its apex 

toward the concavity of the deviation. It may be 

necessary to remove several of these V-shaped 

pieces in order to overcome redundancy, especially 

one on the concave side near the floor of the nose, 

and even the bony septum may be included (Fig. 

54). The so-called "Y-shaped sawfile " devised 

by Fetterolf is preferred for making the excisions 

(Fig. 55 ) . If the incisions are made at the proper 

places and in sufficient number there will be no 

need of great violence in breaking up resiliency. 

Malleable metal tubes are preferred for supporting 

the replaced septum, and may be left in situ many 

^ weeks without risk, since they may be perfectly 

£ fitted to the position they occupy. There is no 

S danger of perforation provided the blood supply 

m is not interfered with by making the incisions too 

5 close together in parallel lines. It is important 

w also to preserve intact the mucous membrane of 

a the septum on the side opposite the cuts. 

A rare variety of septal deformity consists of 
a displacement of the whole mass of the partition 
rf so that its lower border rests on the floor of one 
or the other nostril. There is little or no curva- 
tion or redundancy. Invariably there is more or 
less bending of the anterior nasal spine toward the 
narrow nostril combined with hyperostosis, so 
that the vestibular floor is converted into a mere 
a fissure. Such a deformity is supposed to be an 

gi immediate result of violent traumatism, the asso- 

§1 ciated hyperplasia of bone and cartilage being a 

W natural consequence of the subsequent reparative 

process. For the condition described the supra- 
labial operation of Harrison Allen seems to be 
admirably adapted. Strange to say, it is very 
little known, but its merits have recentlv been 



DEVIATIONS OF THE NASAL SEPTUM. 125 

forcibly urged by A. A. Bliss, from whose description the following 
is condensed. The frenum of the upper lip is first divided with a 
small sharp-pointed bistoury. A chisel with a cutting edge one 
fourth to three eighths of an inch in width is passed into the wound 
upward to the base of the maxillary crest and then driven with a 
few blows of the mallet directly backward through the nasal spine 
as far as the nasopalatine foramen. At once it will be found possible 
to push the septum over with the finger as far as may be desired, 
provided the section has been complete. Unless the premaxilla is 
unusually high, so that the floor of the vestibule is on a higher plane 
than the floor of the naris in general, the mucous membrane will not 
be perforated by the chisel. In any case the accident is not of much 
consequence. The septum is held in its corrected position by means 
of a rubber tube splint, cold water dressings are applied externally, 
and the nares are sprayed every two hours with an alkaline anti- 
septic solution. The operation is done under light etherization, and 
roughnesses may be smoothed down at once or later under cocaine. 
The simplicity of this procedure, its effectiveness and the absence 
of marked reaction commend it in this peculiar form of septal devia- 
tion. The patient is kept in bed a day or two and the tube is dis- 
pensed with after the second week, making the duration of treatment 
about the same as in other operations. 

The fact has been mentioned that one of the earliest methods re- 
sorted to for relieving the subjective symptoms caused by a deviated 
septum was the formation of a perforation by punching out more or 
less of the deformed cartilage. Later attempts were made to save 
the mucous membrane by dissecting it from the cartilage and resect- 
ing as much of the latter as might seem desirable. Among the first 
to do this operation was Ingals, who removes a triangular segment 
of cartilage from the anterior face of a convex deviation, then de- 
taches the posterior remnant of cartilage from the floor of the nose, 
forces it into the median line and holds it in position by a tampon 
of lint charged with iodoform and boric acid. The cartilaginous 
triangle removed has its apex above and its base below, and its 
dimensions vary of course with the degree of deformity. The bony 
ridge jutting from the floor of the nose which supports the septum 
must he removed with saw, chisel, or trephine. In cutting the car- 



126 



DISEASES OE THE NOSE AND THROAT. 



tilage Sajous' knife is used and care is taken not to damage the 
mucous membrane covering the concavity. If the depression is 
abrupt or angular it is difficult to avoid perforating, but the flaps of 
mucous membrane formed on the convexity will cover such a lesion. 
The direction and extent of the primary incision through the mucous 
membrane must vary with the shape of the deformity, and the soft 
parts are separated from the cartilage with a specially designed spud 
so as to give a wide exposure of the latter. Escat is quoted by 
Shurly as practicing a submucous injection of water in order to lift 
off the membrane covering the concavity and thus protect it from 
injury while the cartilage is being incised. Anteriorly the soft tis- 




Fig. 56. Krieg's Operation for Angular Deflection of Septum. 



sues are quite adherent and must be dissected up, while posteriorly 
it is easy to raise them with a suitable elevator. 

The "window resection" operation of Krieg aims to remove all 
of the deflected cartilage from between the layers of mucous mem- 
brane, while Boenninghaus also removes the bony septum so far as 
it may be involved (Fig. 56). Relying upon the assumption that 
the nasal septum is merely a partition and in no sense a support to 
the external nose Otto Freer, without knowledge of having been 
anticipated, has recently advocated an operation practically identical 
with that of Krieg and Boenninghaus, differing only in one particu- 
lar. Instead of removing the bony septum he fractures it with 
Roe's forceps after having fissured the bone with chisel or trephine. 
No intranasal splints are needed, but it is his custom to pack the 



DEVIATIONS OF THE NASAL SEPTUM. \2J 

nostril with a strip of lint loaded with powdered subnitrate of bis- 
muth. This dressing is said to remain aseptic for at least ten days. 
The objects of the tampon are to prevent secondary hemorrhage and 
to hold the flaps in place. The operation is done under local anes- 
thesia with cocaine crystals, which are claimed to give most complete 
insensibility to pain with a minimum of toxic effects. In some cases 
chloroform must be used when the forceps is applied to the bony 
septum. In addition adrenalin provides a bloodless operative field. 
It is said that in some cases new cartilage and bone are regenerated 
from the preserved perichondrium and periosteum. Experience 
with the method up to the present time seems to show that this is not 





b 

Fig. 56. " Window-resection " Operation for Curved Deflection to Right 

with Lower Border of Septal Cartilage Projecting in Left Naris. 

(Krieg.) 

essential, and the mucous membrane in the course of time resumes 
its function and becomes moist and free from incrustation. Such an 
operation demands great patience on the part of the operator and 
extraordinary fortitude in the patient, since its completion requires 
an hour or more. Yet the ultimate results are declared to be so 
satisfactory that it seems worth while to resort to it in certain in- 
tractable deflections, including the bony septum. 

In hardly any other field is the fact so conspicuous that the per- 
fection of an operative procedure is due not to a single individual 
but to contributions from many sources. Although these operations 
on the nasal septum carry personal titles, which for convenience they 
are likely to retain, yet in no instance can it be said that they are 



128 



DISEASES OF THE NOSE AND THROAT. 



the exclusive creation of those whose names they bear. Thus the 
Asch operation, which is just now popular in this country, is really 
an adaptation of various new and useful technical details to a prin- 
ciple which has long been recognized. 

This operation must be done under general anesthesia and with 




Fig. 57. Asch's Instruments for Deviated Septum Operation. 
a, Compressing forceps ; b, angular scissors ; c, straight scissors ; d, sharp 
separator ; e, blunt separator. 

the head of the patient dependent, in what is known as Trendelen- 
berg's or Rose's position. Thus the risk of blood or coagula being 



DEVIATIONS OF THE NASAL SEPTUM. I 29 

drawn into the larynx is abolished (Fig. 57). The special instru- 
ments required are first a pair of scissors, somewhat after the pattern 
of a " button-hole " scissors, that portion of the shank between the 
cutting edge and the joint being curved outward to avoid compress- 
ing the columna when the instrument is closed. Second, a curved 
gouge for breaking up adhesions. Third, a septal forceps, of the 
Adams' or similar design. Fourth, an intranasal splint to hold the 
parts in position until repair is complete. Various shapes and mate- 
rials have been experimented with, tin, cork, Bernays' sponge, soft 
rubber and hard rubber. A hollow tube, made of the last mentioned 
material, flattened laterally and with its anterior end larger and 
shaped to fit the vestibule of the naris gives the best satisfaction. 
Some of these vulcanite nasal tubes have numerous perforations into 
which the mucous membrane is supposed to protrude and thus pre- 
vent the tube from slipping. By many a smooth tube is preferred, 
and if one of correct size has been selected and the spring of the 
cartilage has been destroyed it will stay in place. It permits nasal 
breathing and drainage and can be easily kept clean with the least 
possible disturbance of the wound. Before the operation the nostrils 
should be thoroughly irrigated with an antiseptic solution. The next 
step is to introduce a finger into the stenosed naris in order to learn 
the precise shape of the deformity and whether adhesions are pres- 
ent. The latter may be broken down with the finger or with the 
gouge. One blade of the scissors, which is blunt and dull, is passed 
into the contracted nostril, the other, which is sharp, into the wide 
nostril, and the cartilage is divided through its whole thickness at its 
point of greatest deviation on a line nearly parallel with the floor of 
the nose. A second cut is then made across the middle of the for- 
mer and as nearly as possible at a right angle to it. Thus the carti- 
lage is divided into four triangular segments nearly uniform in size. 
These segments are then broken at their bases by twisting them 
vigorously with the septal forceps. This step of the operation de- 
mands the exercise of force, since success depends upon its thorough- 
ness, and it is surprising what amount of traumatism these struc- 
tures will tolerate without resentment. A supporting tube should 
be selected as large as the nostril will admit and retain without ex- 
cessive pressure, a matter which it is well to determine beforehand, 

9 



i 3 o 



DISEASES OF THE NOSE AND THROAT. 



by inserting the larger end of the tube into the nostril. It is best 
to proceed deliberately and control the bleeding if possible between 
the stages of the operation. In rare cases the tube and even a tampon 
must be inserted before the hemorrhage can be checked. The patient 
should be kept quiet for a day or two and the parts gently irrigated 
with a warm boric acid solution every twelve hours without moving 




Fig. 58. Nasal Tubes. 



a, Asch's hard 
c, cork. 



rubber ; b, Kyle's malleable ; 



the tube. The occurrence of much pain, marked swelling of the 
external parts, or decided elevation of temperature are indications 
for withdrawal of the tube and possible substitution of a smaller 
size. The secret of success in this, as in all operations for deviation, 



DEVIATIONS OF THE NASAL SEPTUM. I3I 

lies in destroying the resiliency of the cartilage. The intranasal tube 
should be worn for at least two weeks and, in extreme cases, even 
longer and should be large enough to fill the nostril without pro- 
ducing painful pressure (Fig. 58). It should be left undisturbed 
for three or four days, cleansing of the nostril being conducted 
through it by means of douches or coarse spray of alkaline solution. 
The tube may be easily removed after thoroughly washing the nos- 
tril with an alkaline solution and spraying with albolene, and its 
replacement may be made painless by cocainization. Unless some 
special indication arises it is desirable to avoid handling the parts 
more than is absolutely necessary to keep them clean. 

The amount of bleeding occurring during these operations for 
deviation of the septum is frequently considerable but is usually 
arrested by the pressure of the tube with the addition of a plug on 
the opposite side if necessary. As a rule, a tube is placed only in 
the convex side. An accident which sometimes happens is annoying 
but not a source of any great discomfort, namely, the occurrence of 



<^Z± 



Fig. 59. Kyle's Septum Knife. 

necrosis along the line of incision. My personal preference for mak- 
ing the division of the cartilage is a sharp-pointed curved bistoury 
which can be more precisely controlled than the scissors, the incisions 
being made along the lines of greatest deviation and exactly to the 
desired extent. A septum knife, devised especially for this purpose, 
is thought by some to be more convenient (Fig. 59). One of the 
best methods of checking bleeding when not very excessive is the 
introduction of pledgets of absorbent cotton soaked in hot water, or 
adrenal extract. 

As a preliminary to operation it is customary to cleanse the nasal 
fossee thoroughly with a mild formalin solution or a saturated boric 
acid solution. Immediately after the operation for deviated septum 
the parts frequently look unpromising in consequence of thickening 
of the cartilage from overlapping fragments. Not infrequently we 
find projecting from the floor of the nose a spur or ridge from the 
intermaxillary bone which may finally require removal by means of 



132 DISEASES OF THE NOSE AND THROAT. 

a saw, chisel, or trephine. Nevertheless, it is well not to be in too 
much of a hurry to attack these thickenings and irregularities since 
it is remarkable to what extent their absorption is accomplished. 

It is very obvious that repair is retarded and the patient is sub- 
jected to needless discomfort by too much meddling with the parts 
after operation. It is impossible to keep these wounds absolutely 
aseptic and the effort to do so by assiduous cleansing with powerful 
antiseptics is to say the least unwise. While evidence of the bac- 
tericidal power of nasal mucus is not conclusive this fluid does not 
appear to be a good medium for germ growth, and it is certainly a 
clinical fact that wounds of the intranasal structures do uniformly 
well, provided they are not subjected to extraordinary irritation or 
the original violence was not excessive. As a rule, gentle cleansing 
once in twenty-four hours with a simple detergent solution, Seller's 
or Dobell's, will be enough to prevent accumulation and decomposi- 
tion of secretion and will give nature a fair chance. 

An excellent method of treating certain forms of simple deviation 
of the cartilaginous septum without thickening was suggested at 
about the same time by Watson and Gleason, of Philadelphia, their 
methods differing only in certain unimportant details. The opera- 
tion of the latter consists of forming a U-shaped flap of the whole 
thickness of the cartilage by inserting a saw at the lower limit of the 
deflection and sawing first obliquely and then directly upwards as 
far as necessary to include all of the deformity, the arms of the U 
being extended, if need be, by means of a blunt bistoury ; in the case 
of the anterior arm the bistoury is passed on the convex side, and of 
the posterior arm on the concave side, of the septum. In this way 
the lines of incision may be prolonged to any desired extent. The 
flap should be made large enough to completely include the de- 
formity, and is forcibly pushed over to the concave side so as to 
destroy the spring at its attachment above as completely as possible. 
Thus the pendulous U is retained by the margins of the incision. 
The chief advantage of this mode of overcoming the deformity is 
that there is seldom necessity of intranasal support. The disadvan- 
tage is that a considerable amount of irregularity is necessarily left 
and it occasionally happens that slight perforations may exist at 
some part of the wound. With this, as with other modes of oper- 



DEVIATIONS OF THE NASAL SEPTUM. I 33 

ating, it is well to postpone measures for correcting irregulari- 
ties for a considerable time in order to allow the parts to mould 
themselves. 

In Watson's method a similar incision is made upwards at the 
crest of the deviation without going through the mucous membrane 
on the concave side. The muco-cartilaginous flap thus formed is 
forced over to the wider nostril, where it is held by its beveled edges. 
This provides for a horizontal deviation. If a vertical deflection 
coexists a wedge-shaped piece of the cartilage, large enough to dis- 
pose of the redundancy, is excised. 

These operations may be done under cocaine. Most patients pre- 
fer general anesthesia. The latter is indispensable when the forceps 
is to be used in fracturing the osseous septum. Great care should 
be exercised in handling the bony septum, especially its upper por- 
tion. The magnitude of septal operations must not be underesti- 
mated, and the general condition of the patient should be considered. 
In certain physical states the loss of blood and the shock to the nerve 
centers from the intranasal traumatism are elements of grave danger. 
Interference should by all means be postponed until the conditions, 
local and systemic, are restored to a desirable standard. There is 
reason to believe that the disasters which have been chronicled as 
sequels of these operations, but by no means peculiar to them, such 
as hemorrhage, suppurative sinusitis and even sepsis, are referable 
to neglect of careful scrutiny of the patient's condition. It is often 
a difficult matter to decide what is the best operation in a given case. 
In a large majority the Asch operation will give a satisfactory result, 
at least when the bony septum is exempt from deformity. Owing to 
the warnings given by Emil Mayer and by Asch himself, attempts to 
fracture the bone with the forceps are regarded as dangerous. In a 
case reported by Robert Levy fatal sepsis occurred and Freer refers 
to a case in which suppuration of the sphenoidal sinus followed the 
operation. Such accidents as these, and fracture of the turbinates, 
as in the experience of Stucky, would seem to be fairly explained 
by some error in technique or some obscure morbid state in the indi- 
vidual operated upon. The violence required even to fracture the 
bony septum is in no degree comparable with that inflicted in many 
traumatisms with no untoward results beyond merely local damage. 



134 DISEASES OF THE NOSE AND THROAT. 

Hemorrhage in the Asch operation with the head dependent is nat- 
urally more free than when the patient is erect, but has been some- 
what reduced since it became the custom to use a thorough prelim- 
inary application of adrenalin. The objection offered to the Asch 
tube that it is too much curved is overcome in part by Mayer's modi- 
fication and completely by that suggested by McKernon, in which 
the lower border of the tube is straight, and in addition the last has 
its upper anterior border rounded so as to fit into the hollow of the 
nasal vestibule without producing irritation. Moreover, it has 
the advantage of not being perforated. Most of the tubes in 
common use are too small at their distal end to give enough 
support to a deflection extending far back in the naris. All 
tubes made of hard rubber or other inflexible material are unsatis- 
factory for the reason that they cannot be molded to the nostril. 
The latter objection is obviated in the malleable tubes used by Kyle 
and others. The cork splint of Berens and the compressed cotton 
tampon (Bernay's sponge) of Simpson, either of which may be 
readily shaped to suit the case, deserve further trial. The former is 
cut as desired at the time of operation and is made aseptic by being 
coated with iodoform collodion. A thin plate of vulcanite has been 
added by Chappell to the septal surface of the latter, which makes 
the splint firmer and prevents adhesion of the cotton fibers. If the 
cotton swells excessively it is a simple matter with a broad-bladed 
forceps to extract a layer or two from the middle of the splint. 
Wholesale resection of the osseo-cartilaginous partition between the 
nares is not to be unreservedly advised until it can be conclusively 
proved that it is free from risk to the contour of the external nose 
and that it gives results superior to those obtained by other methods 
less tedious. Success will surely attend any method of operating 
which destroys the elastic spring of the septum and disposes of ex- 
cess of tissue by resection or properly planned incisions. 

One of the most annoying complications of a deflected septum is 
a disfigurement of the external nose caused by an abrupt bend at the 
junction of the cartilage with the nasal bones. It is most common 
in traumatic cases and frequently one or the other nasal bone is de- 
pressed. It is impossible to correct the deformity until the bone has 
been restored to its normal place. This may sometimes be done with 



ECCHONDROSIS AND EXOSTOSIS OF THE SEPTUM. 1 35 

a Sinexon's nasal dilator, or with a powerful forceps, like that de- 
vised by Walsham, one blade of which is to be applied within and the 
other outside the nostril. In some cases there is a good deal of thick- 
ening at the prominence of the angle, a result of the original injury, 
which may be shaved down by a guarded electric burr introduced 
through the nostril, the skin having first been dissected from the hard 
parts. Or it may be more comfortably removed by external incision, 
provided the patient is willing to wear the trifling scar that may 
follow such a wound. In most cases cosmetic effects are considered 
less important than restoration of breathing space, yet by the exer- 
cise of a little care and ingenuity much may be done to remedy these 
unsightly distortions. 

ECCHONDROSIS AND EXOSTOSIS OF THE SEPTUM. 

Ridges or spurs of the nasal septum may consist of cartilage or of 
bone. In the former case they are called ecchondroses, in the latter 
exostoses. They may exist quite independently of deflection of the 
septum. Exostoses are met with generally far back in the region 





Fig. 60, a. Ecchondrosis of Septum Embedded in Right Inferior Turbinate, 
with Deep Groove on Opposite Side. (Krieg.) 

of the vomer, although it is not unusual to see indications of ossifica- 
tion in anterior ecchondroses of long standing, especially those near 
the floor of the nose, or a septal ridge may consist of cartilage in 
front and behind of bone. The possible admixture of osseous tissue 
has an important bearing on the selection of a mode of correcting 



I36 DISEASES OF THE NOSE AND THROAT. 

these deformities. A pure ecchondrosis, situated well forward, may 
be readily removed with a bistoury. A long antero-posterior ridge 
should be attacked with a saw, since bony tissue offers too great 
resistance to a knife blade. 

The varieties of shape assumed by these deformities is almost 
without limit. Usually they are very irregular ; rarely they are sym- 
metrical. Most frequently, perhaps, their lower surface is more or 
less horizontal, while above they shade off gradually into the septum 
(Fig. 60). 

The diagnosis of an ecchondrosis is free from difficulty if both 
nostrils be carefully inspected. A septal protuberance is seen in one 
nostril without proportionate depression of the opposite side of the 



( 



o 




Fig. 60, b. Bilateral Ecchondrosis of Septum. (Krieg.) 

septum. The tumor is hard, insensitive, and covered by mucous 
membrane unaltered or tense and thin. At the apex of the spur the 
membrane may be eroded. Exostosis of the septum is less easily 
detected, frequently being concealed by an anterior turbinate enlarge- 
ment or a deviation of the cartilage. The use of cocaine and the nasal 
probe may be essential to its discovery. A septal exostosis rarely 
impedes breathing, but it is believed to be a prominent factor in many 
obstinate derangements in the postnasal region and in the lower 
air track. It must offer more or less obstruction to nasal drainage 
and be a source of irritation by impinging upon or becoming adherent 
to a turbinate body. It is often pyramidal or almost conical in shape. 
It occurs only in adults, a fact which, taken in conjunction with its 
situation on a part of the septum supposed to be protected from 



ECCHONDROSIS AND EXOSTOSIS OF THE SEPTUM. 



137 



injury, would exclude a traumatic theory of etiology. In fact, it 
seems impossible to explain the origin of these singular deformi- 
ties. 

By far the best instruments for removing these overgrowths is the 
nasal saw. The ring-knife or " spoke-shave " is much inferior espe- 
cially in dealing with dense bone. A long thin-bladed saw with 
teeth set and cutting from behind forward has given me the most 
satisfaction. It makes very little difference whether the handle be 
straight or angular, as one may readily become accustomed to either 
(Fig. 61). It is well to make a preliminary cut through the mucous 




Fig. 61. Bosworth's Nasal Saws. 



membrane from below upwards in order to obviate the danger of 
stripping up the soft parts. The excision of the mass itself is most 
conveniently made from above downwards. The saw should be 
applied at an angle until the soft parts are cut through, when it may 
be brought to a vertical position and the section completed, the object 
being to prevent slipping of the instrument and consequent incom- 
plete removal of the redundant tissue. Under cocaine and the adrenal 
extract the operation is painless and almost bloodless. In excep- 



I3§ DISEASES OF THE NOSE AND THROAT. 

tional cases each of these agents may fail to produce its legitimate 
effect, owing usually to individual idiosyncrasy. In the opinion of 
many secondary hemorrhages have been much more frequent and 
serious since their introduction, and firm plugging of the nostril is 
therefore advised by some in all these cases. My own feeling is 
strongly averse to the routine use of the intranasal plug, and my 
experience has been to be called upon to apply it quite as frequently 
before the cocaine-suprarenal era as since the use of these drugs 
became general. Fifteen or twenty minutes after the conclusion of 
the operation, when all oozing has ceased, both nostrils should be 
sprayed freely with the suprarenal solution followed by mentholized 
albolene. The patient should be cautioned to keep quiet, avoiding 
physical exercise and mental excitement for the succeeding twenty- 
four hours, and the necessity of a nasal plug will seldom arise. The 
after-treatment should be limited to keeping the parts clean and to 




Fig. 62. Dessar's Hard Rubber Nasal Bougie. 

preventing the formation of adhesion. The latter may be accom- 
plished by gently passing a probe between the opposed surfaces or 
a hard-rubber nasal bougie (Fig. 62) may be introduced every sec- 
ond or third day. 

The treatment of septal spurs by electrolysis has many advocates. 
There are two methods of applying it, one called the unipolar and 
the other the bipolar system. The latter is more generally practiced. 
The source of electricity may be a thirty-cell galvanic battery, or 
preferably the Edison current, of 100 volts, modified by a suitable 
controller. A strength of from fifteen to forty milliamperes is re- 
quired. The needles may be of steel, or gold-plated, in an adjust- 
able handle. The former material is recommended by Moure and 
others, but a steel needle at the positive pole oxidizes and must be 
renewed at each sitting. Iridoplatinum needles are free from this 
objection and being indestructible may be fixed in a permanent 
handle (W. E. Casselberry). The pain of the operation is very 



ULCERATION OF THE SEPTUM. I 39 

slight under cocaine, and there seems to be no doubt that cartilaginous 
spurs may be dissipated by this method. Bone is not affected by it 
and one objection to its use on the anterior part of the septum is the 
possibility of bony foci in an old ecchondrosis. The energy and 
duration of the current should not be excessive for fear of perfora- 
tion of the septum, an accident which may be avoided by suspend- 
ing the application the moment a mottling of the mucous membrane 
of the opposite side appears. The action of electrolysis is sorbe- 
facient, that of the electric cautery is mainly destructive. Yet in 
reading the histories of reported cases of so-called electrolysis one 
cannot escape the suspicion that many of them belong in the latter 
category. We read of a slough separating at the end of a week fol- 
lowed by a granulating surface with pronounced loss of substance. 
Surely this is not electrolysis ! Many authorities vigorously de- 
nounce the use of the galvano-cautery on the septum. My own 
experience convinces me of its safety and efficiency in ecchondroses 
of moderate dimensions. I am persuaded that much of the preju- 
dice against it is founded upon its improper use in unsuitable cases. 
Electrical methods at best are inferior to cutting and are permis- 
sible only in timorous patients or in those to whom a loss of blood 
might be detrimental. 

ULCERATION OF THE SEPTUM. PERFORATION. 
HEMATOMA. ABSCESS. 

Ulcers of the septum may occur as a result of mechanical irrita- 
tion due to special occupations or may develop in certain sympto- 
matic conditions attended by local vascular changes. The apex or 
the concavity of a deflection is apt to be the site of ulceration owing 
to the lodgment of secretion which the patient is in the habit of 
removing with his finger. This is noticed particularly in young 
people, an abrasion of the septum following a wound due to the 
habit of picking the nose. Ulcerative processes may also follow 
acute fevers, typhoid, or specific disease. In the last the process is 
very apt to begin in the perichondrium or the periosteum and in- 
volve the mucous membrane secondarily. In syphilis the bone as 
well as the cartilage is apt to be affected. This is true of almost 



I40 DISEASES OF THE NOSE AND THROAT. 

no other ulceration occurring in the nose. The situation of the ulcer 
depends entirely upon its cause, but most ulcers are seen about the 
middle of the cartilaginous septum. 

Over-treatment may be resorted to in consequence of the desire 
of the patient to obtain relief. In most cases simple cleanliness fol- 
lowed by the application of mild astringents will be all that is neces- 
sary. Exuberant granulations may need to be removed by cauteri- 
zation or curetting. The formation of scabs should be prevented 
by the application of an ointment of vaselin containing ten grains 
to the ounce of boric acid, or a mixture of white precipitate ointment 
and oxide of zinc ointment in the proportion of one of the former 
and three of the latter. The last mentioned is particularly useful in 
specific ulcerations and, of course, in the latter condition we are 
called upon to adopt at the same time a vigorous constitutional course 
of treatment. A probable result of ulceration, especially when it is 
extensive and deep is a perforation of the cartilage, an accident which 
may not be of serious import, but, on the other hand, may be fol- 
lowed by some inconvenience as well as disfigurement. A perfora- 
tion situated well forward and having thick edges is affirmed by Myles 
to cause the greatest annoyance. A theory of etiology held by C. W. 
Richardson and others is that the destructive process results from 
lowered vitality and resisting power of the cartilage due to 
defective innervation. Tubercular disease is discovered in a con- 
siderable proportion of cases of perforation. Its occurrence in 
workers in mercury, arsenic and other chemicals has long been known, 
and Toeplitz reports having discovered it in a large number of those 
employed in an establishment for the manufacture of Paris green. 
When the perforation involves only the cartilage it is usually of simple 
origin, although the ravages of syphilis may be, in rare cases, limited 
to the cartilaginous septum. Often the perforation may be traced to 
an injury which results in the formation of a liematoma. In the 
majority of cases a hematoma undergoes resolution without destruc- 
tion of tissue ; in others suppuration takes place and the tissues break 
down unless an early outlet is given to the pus. An abscess of the 
septum, if allowed to pursue its own course, almost invariably results 
in perforation with more or less sinking in of the dorsum of the nose. 
It is a curious fact that a perforation of considerable size may exist 



PERFORATION OF THE SEPTUM. 141 

without the knowledge of the patient. It has been many times my 
experience to see almost complete loss of the cartilaginous septum 
after typhoid fever without external deformity or any inconvenience 
resulting. The rapidity of the process and the resulting deformity 
vary greatly in different cases. At a meeting of the Laryngological 
Society of London, W. G. Spencer related the case of a boy in whom 
a hematoma just within the nares followed a fall on the face. There 
was no suppuration or immediate deformity, but two years later the 
bridge of the nose began to sink and the nasal septum became much 
thickened and twisted, probably in consequence of chondritis and 
softening resulting from the injury. There was no history of syphi- 
lis. On the other hand, Haviland Hall referred to the case of a 
woman of sixty in whom a septal abscess destroyed the cartilage and 
caused marked deformity within three or four weeks. It seems to be 
the general belief that in young people during the period of develop- 
ment these occurrences produce more deformity than in adults. Per- 
forations are very apt to give more trouble when their long diameter 
is vertical than when it is horizontal. Frequently a whistling noise is 
noticed in respiration in the former case which is a source of some 
annoyance, and the tendency to incrustation of secretion along the 
margins of the opening is much more pronounced than when the per- 
foration is antero-posterior. It occasionally happens that a perfora- 
tion results from necrosis along the line of incision after the opera- 
tion for deviated septum. 

The treatment of perforation of the septum is limited to a correc- 
tion of the tendency to erosion of the margins ; no operative closure 
of the opening being feasible unless it be very small or the septal 
tissues be so redundant as to permit of a plastic method of closure, 
and, indeed, the disturbance which the condition causes is generally 
so trifling that interference is not warranted. 

It is important that we should recognize the existence of abscess 
promptly in order to evacuate the pus very early by a free incision. 
If the collection of pus is extensive it may be necessary to incise upon 
both sides, but usually a single incision is sufficient. The important 
point is to make the cut near the floor of the nose and wide enough 
to give good drainage. It is well to keep the edges of the cut apart 
by a bit of iodoform gauze until the suppurative process begins to 



142 DISEASES OF THE NOSE AND THROAT. 

abate. At first the pus cavity should be thoroughly washed out with 
peroxid of hydrogen or boric acid solution and the nostrils should be 
cleansed with an alkaline spray or douche. There is seldom any diffi- 
culty in diagnosing an abscess. The tumor which it forms is gener- 
ally bilateral and symmetrical and is distinctly fluctuating to the finger 
or the probe. 

CONGENITAL OCCLUSION OF THE NARES. 

Closely allied to the subjects just considered is that of stenosis of 
the nares by bony occlusion of congenital nature. Many cases of par- 
tial or complete obstruction due to a web of soft tissue or adventitious 
membrane are no record, but those in which the obstacle is bony 
are very rare. Of the latter, in nearly every case the condition has 
been observed in the posterior nasal region. The impediment may 
consist of an exostosis from almost any part of the bony framework 
of the nasal fossa, or of a plate of bone growing from the floor or 
outer wall of the cavity. Unless both choanal are involved the sub- 
jective symptoms may be insignificant. Under the latter circum- 
stances a nursing infant might suffer from the effects of malnutri- 
tion. On the other hand, a single patulous nostril may carry enough 
air to conceal the condition until the child reaches an age to observe 
that but one nostril is doing its duty. In a case of my own, a girl of 
eighteen, no discomfort was caused by the anomaly, except slight 
impairment of hearing on the corresponding side. In this case the 
obstruction was complete and consisted of an outgrowth from the 
hard palate. The septum was deflected towards the stenosed side and 
the turbinate structures in that fossa were almost rudimentary. The 
sense of smell was less acute than normal. With the electro-trephine 
a button of bone one quarter of an inch thick at its lower and one 
eighth at its upper margin was removed, evidently from a plate 
springing from the floor of the nose. The immediate result was 
restoration of the nasal air track and after a few weeks manifest 
improvement in the sense of smell. No impression was made on the 
hearing and the patient was annoyed as she had not been previously 
by accumulation of secretion in the affected nostril. In a case of this 
kind, therefore, the wisdom of interference is doubtful. The state of 



INTRANASAL ADHESIONS. 143 

things is very different, however, in acquired stenosis from a develop- 
ing exostosis or in a condition of double atresia. Here the subjective 
disturbance may be very distressing, or intervention may be impera- 
tive for preservation of life. In order to determine the character of 
an obstruction, whether bony or membranous, it will be necessary to 
explore with the finger in the posterior naris and with a sharp probe 
from the front. A soft obstruction may be penetrated and destroyed 
with the galvano-cautery, one of bone must be attacked with the drill 
or trephine. The tendency to closure by granulation tissue and adhe- 
sions is very marked, and in many cases it has been found necessary 
to use nasal tubes and dilators for a long period in order to preserve 
the patency of the nostril. 

Membranous occlusion may exist at almost any part of the nasal 
passage as a congenital malformation, or as a result of struma or 
syphilis. It may be relieved by multiple incisions, or, if very thick, 
by excision of redundant tissue and the subsequent use of a nasal 
tube so long as a tendency to contraction persists. 



INTRANASAL ADHESIONS. 

An accident likely to occur after cauterization of the turbinate body 
or after an operation upon the septum, especially in a narrow nostril, 
is an adhesion or synechia between the walls of the nasal fossa. Price 
Brown justly lays great stress upon the fact that in many cases this 
results from neglect of after-treatment, the absence of pain and dis- 
comfort leading the patient to underestimate the importance of atten- 
tion. A similar condition may result from erosions or ulcerations 
occurring spontaneously and is frequently seen in the strumous. The 
adhesion may consist of bone, of cartilage or of fibrous tissue. It 
most frequently exists between the middle turbinate and the septum, 
or the turbinates themselves may unite. An ulcerative process may 
be instituted by a foreign body or by pressure resulting from a hyper- 
plastic rhinitis. Adhesions obstruct breathing more or less according 
to their situation and are frequent causes of a variety of reflex distur- 
bances. In many cases a chronic catarrhal naso-pharyngitis or a per- 
sistent tinnitus aurium may be the only prominent symptom. When 
the adhesion is composed of fibrous tissue it may be divided with 



144 DISEASES OF THE NOSE AND THROAT. 

scissors or with the galvano-cautery knife; when composed of bone 
or cartilage the redundant tissue must be removed with a saw or 
drill. In the after-treatment the case should be watched with great 
care in order to prevent recurrence ; and, with this object in view, it is 
important that a considerable bridge of tissue should be removed. If 
care in this respect be observed the use of plugs and tampons will 
be quite unnecessary. On the contrary some consider it safer to 
insert a tampon of rubber tissue or even absorbent cotton soaked in 
albolene, which it is claimed may be left in many days without dis- 
comfort or danger, in the meantime the passage being cleansed daily 
with antiseptic sprays. In the course of convalescence it may be 
necessary to touch exuberant granulations with some astringent solu- 
tion, chromic acid, zinc, or nitrate of silver. Until complete repair 
is accomplished the patient is not absolutely secure against reforma- 
tion of the svnechia. 



COLLAPSE OF THE NOSTRIL. 

In consequence of weakness of the muscular apparatus controlling 
the nostrils or a maladjustment of the lateral cartilages some indi- 
viduals suffer more or less inconvenience from collapse of the ales 
nasi especially during forced respiration and in sleep. The condition 
is frequently aggravated by thickening or by distortion of the col- 
umna nasi or by an ecchondrosis of the septum. In the latter case 
the trouble is restricted to one nostril and chiefly impedes inspiration. 
The difficulty may be overcome by directing the patient to wear a 
tube which supports the nostril and reaches just within the vestibule 
or the so-called nasal dilator, consisting of a pair of pads connected 
by a U-spring, one pad intended for either nostril. The pad or dila- 
tor may be worn only at night or for a limited period during the day. 
At the same time it is claimed that good results may be obtained 
from massage and from electrization of the alar muscles. A septal 
deformity must be corrected. W. J. Walsham succeeded in support- 
ing a collapsed nostril by the following ingenious operation. A flap 
of mucous membrane with its base uppermost was dissected from 
the inner wall of the nasal vestibule. The surface of the depression 
where the lower lateral cartilasfe bends was then made raw. The 



DISLOCATION OF THE COLUMNAR CARTILAGE. I45 

epithelium covering the flap, the width of which was about three 
sixteenths of an inch, was then scraped off, the flap rolled upon itself 
like a bandage and secured in the depression at the border of the 
cartilage by a stitch of fine fishing-gut passed through the septum 
into the opposite nostril and back again. The little ball of tissue 
prevented the ala from caving in during inspiration and the cure 
of the condition is said to have been permanent. Harke, who has 
given a good deal of attention to this subject, notes the frequent fail- 
ure of removal of a posterior obstruction to restore nasal breathing 
owing to paresis or possible atrophy of the muscles which should 
dilate the nostril. He favors mechanical support for the weakened 
structures, and it would seem entirely reasonable to expect results 
from measures intended to improve muscular tone in other situa- 
tions. 



DISLOCATION OF THE COLUMNAR CARTILAGE. 

There is no separate columnar cartilage, the name being applied to 
the reflected portions of the lower lateral cartilages which assist in 
forming the partition between the nostrils. Obstruction of one or 
the other nasal vestibule may be caused by distortion of this cartilage 
or by displacement of the lower border of the cartilage of the sep- 
tum. The entrance of the naris, or limen vestibuli, may be con- 
verted into a narrow longitudinal slit, the outer limit of which is a 
prominent fold on the inner surface of the ala especially described 
by Roughton. When collapse of the nostril is added to these anom- 
alies of the cartilage the affected side becomes almost useless espe- 
cially on inspiration. Attempts have been made to remedy the diffi- 
culty by divulsion and by section of Roughton's band without suc- 
cess. The wearing of rubber tubing in the nostril, or the use of 
nasal expanders, or any form of dilatation is merely palliative. 
These measures give a certain amount of comfort to those who are 
averse to operative interference. If the columnar cartilage is at 
fault a V-shaped incision through the mucous membrane permits the 
cartilage to be exposed and the excess shaved off with a blunt bis- 
toury or scissors. The triangular cartilage is not so readily reached 
for a plastic operation and the projecting portion may as well be cut 



I46 DISEASES OF THE NOSE AND THROAT. 

off en masse without regard to saving the mucous membrane. If 
the area of the latter thus sacrificed is not too extensive the soft tis- 
sues are regenerated and the membrane recovers its function. 
Otherwise more or less scar surface results over which incrustations 
of secretion may give some annoyance. The best remedy for this is 
the application of unguents containing ichthyol or carbolic acid. 
Cocaine should be applied freely and may be injected into the mem- 
brane in case it is necessary to cut near the muco-cutaneous junction. 
No dressing is needed except a pledget of sterilized cotton or gauze 
to hold the flaps in place after a plastic operation. 

FRACTURE OF THE XOSE. 

What is called a broken nose is usually a luxation of the septal 
cartilage. The degree of violence required actually to fracture the 
nasal bones or the intranasal framework is generally so extreme as 
to induce grave symptoms of cerebral damage. The precise location 
and extent of the local lesion may be obscured by swelling, unless 
the case is seen very soon after receipt of the injury, and the diagno- 
sis and treatment may call for the exercise of the utmost skill and 
patience. If the nasal bones are simply depressed it is an easy mat- 
ter to replace them by means of an elevator passed into the nostril 
and retain them in place with pledgets of iodoform or nosophen 
gauze. If they are impacted it is often very difficult to raise them, 
and if the case is complicated by comminution and displacement of 
the septum and perhaps by fracture of the maxilla the problem con- 
fronting us is much more serious. In the latter case some form of 
extranasal apparatus will be required as well as an intranasal sup- 
port. Restitution of displaced parts having first 'been effected, the 
nostrils may be plugged with iodoform gauze, or a rubber hood, or 
finger-stall, may be inserted and stuffed with the desired quantity of 
sterilized cotton. Either of these will check hemorrhage and give 
adequate support, but the latter is more readily removed. Both of 
these are objectionable because they compel mouth breathing, and to 
avoid the discomfort of that condition a hollow tube of rubber, vul- 
canite, or malleable material, like that used after an operation for 
deviated septum, may be introduced and around it cotton or gauze 



FRACTURE OF THE NOSE. 1 47 

may be packed as needed. For an external splint successive layers 
of gauze impregnated with plaster of Paris, which are moistened 
and then molded properly and allowed to set, will be found satis- 
factory. A splint made of sheet zinc and lined with felt extending 
from the tip of the nose to the forehead is recommended by W. 
H. Daly. This is molded to the nose and held in place by five 
tails, two at its lower edge which pass around the head under the 
ears, two from its upper edge across the forehead and above the ears, 
and a fifth which passes backward over the vertex from its upper 
margin. The five ends are fastened together at the back of the head. 
F. C. Cobb advises a firm head-band of steel, to which are attached 
pads capable of being adjusted to any part of the nose and the 
pressure of which may be regulated according to necessity. It is 
prevented from slipping by bands going across the head and under 
the chin. A rather ingenious splint has been devised by Jesse Hawes 
for a bad case of fracture in which he was annoyed by an upward 
tilting of the tip of the nose. It consists of a piece of No. 15 spring 
brass wire bent in the form of a rectangular letter U, long enough to 
extend from the middle of the upper lip over the top of the head. 
The arms of the U are intended to rest on either side of the nose, 
its lower portion being slightly bent outward so as to avoid pressure 
on the upper lip. Each arm is bent sharply forward at an angle 
opposite the supraorbital ridge and a second time in such a way as 
to carry it backward over the top of the head. The angles of the 
wire well padded are pressed firmly under the supraorbital ridge 
where they are held by a broad band of adhesive plaster, completely 
encircling the head above the eyes. The tip of the nose is then 
drawn down by means of silk ligatures passed through the septum 
and the mucous membrane and cartilage of the alse and fastened to 
the transverse part of the splint. Depressed portions of the nose 
may be supported by means of intranasal springs of wire covered 
with rubber tubing and attached to the horizontal arm of the splint. 
The elastic property of rubber may be utilized in an external support 
of tubing, especially when lateral displacements exist. Many sur- 
geons discard splints of all kinds, relying wholly upon the natural 
support given by the arch of the nasal bones. Perfect results 
are secured provided readjustment of the parts to a normal posi- 



I48 DISEASES OF THE NOSE AND THROAT. 

tion has been accurate. In exceptional cases following extraordinary 
violence, or when a tendency to recurrence of deformity is displayed 
some form of splint may be required. Under ordinary circum- 
stances with an Adams' or Asch's septum forceps and by manipula- 
tion of the external nose with the fingers a fracture may be reduced 
with cocaine anesthesia. In children and in complicated cases general 
anesthesia is a decided advantage. J. Wright reminds us of many 
curious and some valuable expedients familiar to the ancients, who 
were evidently acquainted with the objection, which most of us share 
in modern times, to the prolonged retention of absorbable material 
in the nasal fossae. Plugs of cotton or gauze are far inferior to vul- 
canite or metal tubes. When a broken nose has been neglected and 
fragments have become consolidated in a false position it is not easy 
to restore the normal contour of the nose. It may be necessary to 
refracture the nasal bones, and for this purpose Walsham has de- 
signed a powerful forceps, one blade to be applied externally and 
the other internally. This involves more or less contusion of the 
skin, to obviate which J. O. Roe advises intranasal dissection of the 
skin from the surface of the bone and applying both blades through 
the nostril. E. J. Senn advocates exposure of the nasal bones by 
an incision along the dorsum of the nose and dissection of the soft 
parts. The bones are then broken with a small chisel, mobilized and 
shaped by means of a padded elevator introduced through the nos- 
tril, and held in place by passing a needle armed with silver wire 
transversely under the fragments, the ends of the wire then being 
attached to disks of lead, or preferably cork or other pliable sub- 
stance. The disks should be well padded with gauze. Intranasal 
splints of rubber tubing are inserted, the external wound is carefully 
stitched with fine sutures, and over all a plaster of Paris mask is held 
with adhesive strips. The wire is withdrawn in five or six days, the 
tubes and the plaster mask in fifteen to eighteen days. 

In many of these cases the nasal bones are not involved, but the 
septum is distorted and thickened, the redundant tissues permitting 
a resort to a series of subcutaneous plastic operations like those 
described by Roe. A transverse depression of the dorsum below the 
nasal bones, or a marked divergence from the middle line of the 
tip of the nose may be thus corrected. In other cases, when the 



FRACTURES OF THE NOSE. 1 49 

traumatism has been considerable, the train of events comprises the 
formation of a hematoma of the septum, followed by suppuration, 
perforation and more or less loss of tissue. Under such circum- 
stances it often happens that some kind of prosthetic device or an 
external plastic operation may be required. In some cases of old 
fracture followed by saddle-back deformity the plan of making an 
incision along the dorsum or transversely above the alee and insert- 
ing a plate of metal gutta-percha, or celluloid has been successful, 
while in others the foreign body provoked irritation and had to be 
removed. The subcutaneous injection of paraffin, to be referred to 
more at length in the chapter on Syphilis, is well adapted to these 
cases. The experience of Moszkowicz, in Gersuny's clinic, shows 
that a mixture of solid and liquid paraffins in such proportion as to 
give a melting point of from 96.8 to 104 F. works most satisfac- 
torily. It is said never to be absorbed, but becomes encapsulated and 
eventually is penetrated by a network of new connective tissue. 



CHAPTER VI. 

NASAL POLYPI. 

The term nasal polyp properly refers to a gelatinous swelling or 
tumor of the mucous membrane of inflammatory origin. Some au- 
thorities use it indiscriminately to include various forms of benign 
neoplasm. As a matter of fact, a true polyp is in no sense a neo- 
plasm, although for a long time it was wrongly called " myxoma." 
Attention has been drawn to the erroneous use of the latter term by 
Hopmann and Chiari, and in this country by Jonathan Wright. In 
some cases of long standing the proportion of connective tissue is in 
excess and gives to the mass a considerable density. Recent polyps 
have a pulpy character and consist in large part of fluid. This feat- 
ure is so marked that the qualifying adjective " edematous " is used. 
In some respects a polyp develops like granulation tissue, cellular 
elements predominating. It grows more vascular, increases in size 
by its own weight and finally becomes distinctly pedunculated. The 
formation of cells and fibrous tissue goes on indefinitely, the serous 
infiltration progresses at the same time, until a mass resembling a 
new growth is presented. The process described presupposes the 
existence of a condition of inflammation, yet it is rather unusual to 
see a well-defined polyp develop in the course of an acute attack of 
rhinitis. As a rule nasal polypi are multiple and are observed in 
both nostrils, more frequently in men than in women, possibly in con- 
sequence of the relatively greater exposure of the former to the 
causes which produce inflammation of the nasal mucous membrane. 
Although there is, perhaps, no special diathesis predisposing to poly- 
poid formation it is not uncommon to find examples of the disease in 
several members of the same family. The well-known theory that 
polypi are symptomatic of disease of bone is not generally accepted, 
although in advanced cases it must be admitted that a tendency to 
the involvement of bone is shown. Nasal polypi are seldom seen 
in children ; they are essentially a disease of adult life. 

150 



NASAL POLYPI. I 5 I 

The bone changes taking place in many old cases of nasal polypi 
are often more important than the polyps themselves. Attention 
restricted to the latter will not prevent recurrence. A very radical 
operation, including the bony structure, is essential, and oftentimes 
it is necessary to remove nearly the whole of the ethmoid bone. To 
be sure of keeping within the bounds of safety we should advance 
with great caution, removing the tissue piecemeal with curette or 
small cutting forceps. Chronic multiple polypi attended by pus for- 
mation and bone disease will seldom yield until we resort to radical 
procedures of this character, if necessary under a general anesthetic. 
Doubtless many cases of nasal polyp can be cured, without touching 
the bone, by repeated operations, but in old cases when disease of the 
bone is well established nothing short of its removal will suffice. 

The theory of Woakes that nasal polypi are a direct consequence 
of a " necrosing ethmoiditis " has met with much opposition and 
would seem to be conclusively refuted by those cases of polyp seen to 
spring from the surface of the nasal septum, or from the wall of a 
sinus, in which there is no suspicion of bone disease. Soon after 
its announcement Martin, whose histological studies furnished a basis 
for the theory, declined to accept it, and later Lennox Browne and 
Spencer Watson asserted that none of the clinical features of necro- 
sis can be discovered in polyp cases. Baumgarten believes that 
necrosis is a frequent but not invariable accompaniment of ethmoidal 
suppuration, while Grimwald declares that polyps may be associated 
with empyema of any of the accessory sinuses and not exclusively 
of the ethmoid cells. Hajek combats the theory of Woakes and 
maintains that ethmoid disease is merely a late stage of inflammation 
extending from the surface, the process being favored by the relative 
thinness of the mucous membrane in the region where polyps are 
usually found. The osseous fragility mistaken for necrosis may 
occur as resorption of previously compact bony tissue or as new for- 
mation of bone, and necrosis is always a result and not a cause of 
deep-seated inflammation. 

Inflammatory processes in the ethmoid region simply vary in de- 
gree and may be superficial, may affect the medullary substance of 
the middle turbinate, or may involve the framework of the ethmoid 
labyrinth. The ease with which the deeper structures arc invaded 



152 DISEASES OF THE NOSE AND THROAT. 

is explained by the direct continuity found to exist between the 
mucous membrane and the medulla of the bone. The changes in 
the bone consist of new formation and resorption, thickening and 
rarefying osteitis, the two processes going on at the same time, one 
or the other usually being in excess, but neither occurring alone. 
Cordes is of the opinion that polyps may or may not be indicative of 
sinus disease, that affections of the bone may be either primary or 
secondary, and that a tendency to recurrence must be accepted as a 
sign of bone involvement. The evidence that sinus disease is an 
etiological factor in nasal polypi is far from convincing, although 
these conditions no doubt often coexist. In this connection the an- 
nouncement by Lichtwitz and other observers of the discovery in the 
post-mortem room of many cases of pus in the antrum which gave 
no sign during life is of interest, and yet it is quite incorrect to 
assume that every such accumulation of fluid should be regarded as 
a sinus empyema. In the bone changes referred to the periosteum 
is thickened and crowded with large nucleated cells. The surface 
of the bone is marked by depressions filled with large cells, many of 
which are multinucleated. The bone cells are abnormally large and 
numerous. At points where the process has reached an advanced 
stage are found groups of osteoclasts surrounding areas of disin- 
tegrating bone undergoing absorption. 

The theory referred to has a recent advocate in Lambert 
Lack, who defines a nasal polyp as a localized patch of edema- 
tous mucous membrane dependent upon subjacent bone disease. 
Glandular elements are often very pronounced and not infre- 
quently dilatation and cystic formation result from obstruction of a 
gland duct. In every case of polyp, whether moderate or extensive, 
examined by this observer bone lesions of the nature of rarefying 
osteitis and not a true necrosis were found. Evidences of bone dis- 
ease may be detected by careful examination with the finger under 
general anesthesia. Spicules and loose pieces of bone embedded in 
soft gelatinous mucous membrane may be plainly felt. A blunt 
probe may be used but is likely to pierce the friable tissue and come 
in contact with the bone, thus possibly giving a false impression of 
necrosis. In some cases of long standing it may be discovered that 
the turbinate body has undergone absorption, having been entirely 



NASAL POLYPI. 153 

replaced by a mass of pulpy soft tissue. In others more recent the 
interior of the middle turbinate bone gradually disintegrates and the 
cell in its anterior end expands and forms a bony cyst sometimes 
reaching extreme dimensions. This process, which has been de- 
scribed in another section, often occurs quite independently of poly- 
poid degeneration in the mucous membrane and indeed the latter may 
be in a condition of advanced atrophy. 

From the standpoint of treatment Lack divides polyp cases into 
four classes. (1) Those in which the polyps are few and the proc- 
ess in the bone has subsided. Removal with the snare effects a per- 
manent cure. (2) Cases of incipient bone disease with enlargement 
of the turbinate and edema of the mucous membrane. Here the 
anterior end of the bone, or as much as may be necessary, is to be 
removed. (3) Cases more advanced than the preceding in which a 
few polyps and a limited area of bone disease are present. In addi- 
tion to the snare, the loop of which should be adjusted as high as 
possible around the base of the growth, cutting forceps and the ring 
knife for curetting are useful, the latter being employed under ni- 
trous oxide anesthesia and good illumination. (4) Cases of exten- 
sive bone disease and multiple polyps. A radical operation under a 
general anesthetic is indicated in this condition. A spoke-shave, or 
forceps, is used for removing the principal masses, a large ring 
knife, or Meyer's adenoid curette, is recommended for completing 
the operation. The scraping should be done cautiously, especially 
in the region of the cribriform plate, the morbid tissues being iden- 
tified from time to time by digital examination. Healthy tissue is 
smooth, firm and resistant to the knife as well as the finger. If the 
posterior part of the ethmoid is to be attacked the nasopharynx is 
first tamponned, and in all cases the operation is done with the 
patient turned well over on the side. On the completion of the 
operation the nostril is packed with gauze soaked in glycerin-iodo- 
form emulsion, the dressing being changed and the nose irrigated 
every two or three days. Uniformly good results are claimed for 
this mode of operating, which presents decided advantages over the 
tedious nibbling operation in common practice. Some ecchymosis 
about the eye is a not unusual sequence. A suppurative otitis is not 
more common after this than other procedures and cerebral compli- 



I 54 DISEASES OF THE NOSE AND THROAT. 

cations have never been noted. Febrile reaction, especially frequent 
in sinus cases, subsides on withdrawal of the packing and a resort to 
nasal irrigation. 

In elderly people and in individuals with organic disease or a weak 
constitution, intranasal surgery of even moderate severity is often 
followed by alarming reaction. An operation of the magnitude of 
that just described involves an intolerable degree of shock and milder 
methods in repeated sittings must be preferred. In fact, the pro- 
portion of cases in which such extensive sacrifice of tissue is de- 
manded is extremely small, although there are doubtless inveterate 
and recurring cases which can be cured in no other way. 

The symptoms of nasal polypi, at the outset, are those of acute or 
chronic rhinitis and usually begin with what the patient himself calls 
" cold in the head." Instead of a disappearance of the obstruction 
as usually experienced after recovery from a cold the nasal stenosis 
is persistent. If one side is affected the patient may not suffer ex- 
treme inconvenience ; but if both nostrils are involved mouth breath- 
ing results with its usual discomfort. Asthenopia or other ocular 
disturbances, reflex neuralgias, cough and asthma are among the 
disorders which nasal polypi are known to excite. In well devel- 
oped cases the patient may be conscious of a movement of a pedun- 
culated polyp during nasal respiration. If its pedicle be unusually 
long the polyp may present itself at the anterior naris and if its 
attachment becomes excessively attenuated it may be actually blown 
out in the use of the handkerchief. There is usually a profuse dis- 
charge of watery secretion and speech acquires the so-called nasal 
quality. The sense of smell is impaired or completely lost either 
from mechanical obstruction to the admission of odoriferous particles 
or from degeneration of the mucous membrane of the olfactory tract 
with the contained nerve filaments. Accessory sinus disease may 
result from obstruction to the outlet of a sinus especially in cases 
complicated by bone involvement, or may itself institute a condition 
of the mucous membrane predisposing to edema and polypoid devel- 
opment. 

On inspection a mucous polyp appears as a bluish, opalescent, 
semi-transparent tumor frequently crossed by small blood-vessels and 
bathed in watery fluid with occasional flakes of purulent secretion. 



NASAL POLYPI. I 55 

On puncture the fluid contents escape and the tumor shrivels up 
more or less. Its apparent capacity for absorbing moisture, often 
noticed by the laity, is remarkable and the symptoms it produces are 
much aggravated in damp weather. On examining with a probe the 
fact that it is pedunculated may be readily demonstrated. It is a 
clinical fact that a polyp situated at the posterior naris is more firm 
than one in the interior of the nasal fossa owing to the normal pre- 
dominance of fibrous tissue in the former region, a feature which is 
to some extent true of anterior polyps as a result of irritation to 
which the latter are subjected. In a very large proportion of cases 
the favorite site of polypi is the margin or free surface of the mid- 
dle turbinate body. When a sinusitis coexists they are often seen 
springing from the lips of the ostium maxillare. They rarely arise 
from the septum although adhesions may take place between a polyp 





Fig. 62a. Nasal Polypi. (Griinzvald.) 

and the septal surface. They may develop to such a degree as to 
displace the septum or expand the nasal fossa so as to produce con- 
siderable facial disfigurement. They are rarely single and, in some 
cases, an immense number have been removed ; in all probability 
under the latter circumstances the polyps were really compound, 
several being attached by a common pedicle. They are almost al- 
ways associated with hyperplastic and later with atrophic changes 
in the mucous membrane of the turbinate bodies as well as of the 
septum. They may remain without decided change for a long 
period, but seldom disappear spontaneously (Fig. 62a). 

The prognosis is good, provided the patient will submit to treat- 



I 56 DISEASES OF THE NOSE AND THROAT. 

ment of a character and for the time necessary to accomplish a cure. 
When polyps are symptomatic of sinus disease the prognosis is nat- 
urally less favorable, and a cure is dependent upon correction of the 
sinus trouble. The tendency to recurrence is marked unless the 
underlying inflammatory condition, or bone lesion, is capable of 
relief. 

The treatment consists in removal with instruments or destruction 
of the mass by cauterization. In former times it was a common 
practice to inject astringents into the substance of the tumor such as 
preparations of iron, zinc, or tannic acid and more recently a solu- 
tion of ethylate of sodium has been recommended by B. W. Richard- 
son as being more effective than the other agents mentioned. A 
crude method of removing these growths in old times consisted in 
introducing a polypus forceps, seizing whatever happened to fall 
between its blades and by a process of twisting and pulling, dragging 
from the nasal fossa as much tissue as the instrument might grasp. 
It was a fortunate circumstance if the whole turbinate bone were 
not removed together with the polypoid mass. It is impossible by 
this method to operate with precision or safety and in consequence 
the forceps have been abandoned in favor of the snare except pos- 
sibly in cases of very small circumscribed growths whose attach- 
ment can be clearly defined. 

The bleeding excited by avulsion of a nasal polyp usually pro- 
hibits any further operative interference for the time being, whereas, 
with the cold wire snare it is possible to proceed with such delib- 
eration as to make the operation completely bloodless. The number 
of snares in the market is somewhat appalling. My own preference 
for ordinary routine work is Sajous' modification of the Jarvis in- 
strument (Fig. 25). In the Sajous snare the loop is held at the 
distal end of the stylet which permits more exact manipulation than 
with canulated snares in which the wires are fastened in the handle 
of the instrument and are sure to twist on attempting to turn the 
loop. The capacity of the Sajous snare is limited by its screw 
thread ; in other words the loop cannot be larger than the thread of 
the screw will exhaust. In using the snare for very large polyps 
the Jarvis instrument which permits an unlimited expansion of the 
loop is preferable. This is especially true of polyps which project 



NASAL POLYPI. I 57 

into the nasal pharynx and where the loop is to be manipulated with 
the assistance of the finger passed through the mouth behind the 
velum. In ordinary cases for routine work the Sajous snare is found 
thoroughly satisfactory. The loop is introduced in a vertical posi- 
tion between the polyp and the septum, then turned horizontally and 
crowded over the base of the growth. Care should be taken to hold 
the instrument firmly after it has once been placed and the thumb 
screw when the loop has become engaged may be turned slowly or 
rapidly at will or as the patient permits. Some prefer the hot wire 
ecraseur, but it seems better to cauterize if need be after removal of 
the polyp. In most cases cauterization is quite unnecessary and the 
danger of damaging healthy mucous membrane with the heat should 
not be lightly considered. It is well to cocainize the parts as thor- 
oughly as possible before adjusting the loop, although it is difficult 
in these cases to get satisfactory anesthesia, and inconvenience from 
hemorrhage is greatly reduced by the use of suprarenal extract. 

Many operators prefer an angular snare in order to preserve an 
unobstructed operative field. In those cases of nasal polyp in which 
the turbinate body itself, including the bone, must be in part sacri- 
ficed division of the structures should be very slow and any super- 
fluous weight in the instrument is objectionable. It is an advantage 
to have as little metal in the snare as may be consistent with strength. 
My own favorite Sajous snare, which has " uncapped " a multitude 
of turbinates, weighs only about half an ounce. 

The after-treatment of polyp cases is very simple and should be 
limited to the use of cleansing and antiseptic sprays. Hemorrhage 
is rarely so free as to require special attention, but occasionally a 
firm tampon is necessary. The patient should be kept under obser- 
vation for some time in order to meet the first indications of recur- 
rence and to correct the catarrhal condition invariably present. 



CHAPTER VII. 

BENIGN TUMORS AND MALIGNANT DISEASE OF THE NASAL FOSSAE. 
FOREIGN BODIES. RHINOLITHS. EPISTAXIS. 

Fibroma of the nasal fossa is one of the most unusual of neo- 
plasms. In the naso-pharynx it is more frequent owing to the fact 
that fibrous tissue is more plentiful at the upper and posterior parts 
of the nasal cavity and in the vault of the pharynx than elsewhere 
In the upper air track. The admixture of fibrous tissue in sarco- 
matous and other tumors is not infrequent ; but a pure fibroma is 
rare (Fig. 63). 

The degree of nasal obstruction caused by a fibroma depends upon 
its location and dimensions. The tumor is usually smooth, round, 





Fig. 63. Section of Nasal Fibroma. (Author's specimen.) 

symmetrical and of a darker color than an ordinary polyp, and evi- 
dently is much denser in structure. It is usually distinctly pedun- 
culated and can hardly be mistaken for a tumor of any other charac- 
ter except possibly an old nasal polyp. 

A case of pure fibroma of the nasal fossa came under my observa- 
tion several years aero. It occurred in a young man of twenty-one 



BENIGN NEOPLASMS OF THE NASAL FCSS.F.. I 59 

who complained of catarrhal symptoms and obstruction of the left 
nostril. There never had been any hemorrhage, the sense of smell 
had not been impaired and the general health was excellent. The 
patient had some cough with moderate expectoration, but there was 
no suspicion of pulmonary disease. On anterior rhinoscopy a mova- 
ble tumor could be detected in the left posterior naris attached to the 
end of the middle turbinate. On posterior rhinoscopy the tumor 
seemed nearly to fill the left choana. It was smooth, round, sym- 
metrical and darker in color than a gelatinous polyp, but was sup- 
posed to be a tumor of that kind containing an unusual proportion 
of fibrous tissue. It was removed with a cold wire snare without 
difficulty and with relief of the catarrhal symptoms. Under the 
microscope there was no trace of myxomatous tissue. The tumor 
was dense, non-vascular, and near its surface were collections of 
small round cells suggesting sarcoma, but doubtless of inflammatory 
origin. The fibrous structure was very marked, especially at the 
center of the tumor. 

There is no difficulty in removing a nasal fibroma by the methods 
used in the treatment of nasal polyps, namely, with the cold wire 
snare, or if the pedicle is very thick and vascularity is suspected, the 
cautery loop. 

A fibroma of the naso-pharynx seems to be a very different type 
of neoplasm. Many of the cases on record were undoubtedly mixed 
in structure and had a semi-malignant character. They are decidedly 
recurrent and many of the naso-pharyngeal fibromata reported were 
subjected to repeated operations before their final disappearance. 
The last mentioned neoplasms are, also, more vascular and they are 
not amenable to ordinary modes of treatment. Several of those on 
record were notably reduced in size by the use of electrolysis and 
the operation for their removal, when of large size, by the usual 
surgical procedures is so appalling that electricity offers a desirable 
substitute for the knife. In many cases the growths are so large as 
to necessitate division of the soft palate or even excision of the upper 
jaw in order to give satisfactory access. 

Among the rarer neoplasms met with in the nose may be men- 
tioned osteoma, enchondroma, angioma and cystoma. 

True papillomata, or warty growths, are of somewhat more fre- 



l6o DISEASES OF THE NOSE AND THROAT. 

quent occurrence (Fig. 64). There seems to be no doubt that some 
observers have mistaken simple hyperplasia of the mucous membrane 
for papilloma. Usually they appear anteriorly in the nasal cavity 
and they seldom attain very great size. They are more or less 
pedunculated and irregular in contour. They may resemble mucus 
polypi in color but are less smooth and regular. It may be difficult 
to establish a diagnosis without the aid of the microscope. Usually 
removal with the snare or scissors, followed by cauterization of the 
base, is successful in disposing of them. 

A bony tumor, or osteoma, in the nasal fossa is extremely rare 
and is usually unmistakable in character from the resistance it offers 
to the probe or exploring needle. Generally it is found to invade 
the nasal cavity from one of the accessory sinuses. It is a most 



\J 




Fig. 64. Papilloma of Septum, Left Side. (Griinwald.) 

serious lesion and can be reached, as a rule, only by an extensive 
external operation. 

Cartilaginous tumors are still more rare. They present symptoms 
very similar to those of osteomata and are handled in a similar way. 
An ecchondrosis, or inflammatory thickening of cartilage, is ex- 
tremely common and should not be confused with a chondroma, or 
tumor composed of cartilage. The former involves the septum and 
seldom is seen in the young. A chondroma usually occurs early in 
life, is single, and is not necessarily connected with the septum. 

A T asal cysts have been observed in a very small number of cases, 
not more than three or four such having been recorded. Cystic 
changes in old nasal polypi are not uncommon. A simple retention 



BENIGN NEOPLASMS OF THE NASAL FOSS.E. l6l 

cyst may be met with at almost any part of the upper air track, while 
dermoid cysts are rarely seen elsewhere than in the nasal cavities. 
A genuine cystoma, or cystic dilatation of the normal lymph-chan- 
nels, is usually found in adults and may develop at almost any situa- 
tion. One case of the kind in my experience, in which the tumor 
occupied the floor of the nose in the left vestibule, was cured by free 
incision and packing the cavity with sterilized gauze. 

In spite of the fact that the Schneiderian membrane is highly vas- 
cular, angiomata very seldom occur in this locality. Doubtless many 
cases reported as such have been confused with other neoplasms 
richly supplied with blood-vessels. No cause for their development 
can be discovered, although it probably exists in some condition of 
malnutrition affecting the walls of the blood-vessels. 

The symptoms are such as would result from interference with 
nasal breathing and drainage added to epistaxis which may be severe 
or so frequent as to affect the general health. 

Pathologically these neoplasms consist primarily in a dilatation 
of the blood-vessels whose walls, supported by a network of con- 
nective tissue, become very much thinned and easily rupture. An- 
giomata may spring from a turbinate body or from the septum; 
usually they have been seen in the latter situation near the anterior 
nares, constituting the so-called " bleeding polyp of the septum." 

Their appearance is characteristic. An irregular, elastic tumor 
of reddish or purplish color, from which hemorrhage may be readily 
excited by rough handling, is seen attached to the mucous mem- 
brane by a broad base or a much constricted pedicle. It is of slow 
growth and there is no danger attending it aside from hemorrhage 
which may be prevented by the selection of a suitable mode of treat- 
ment and the avoidance of violence. 

Either the cold-wire or the galvano-cautery snare may be used in 
its removal. The loop should be adjusted well down upon the base 
of the tumor and should be tightened very slowly, especially if the 
cold-wire ecraseur be employed. Recurrences after thorough extir- 
pation are not usual. 

It is obvious that a great deal of confusion exists in the nomen- 
clature of intranasal neoplasms. For example the term " papil- 
loma " has been erroneous])- applied by Hopmann and others to 
1 1 



; 



1 62 DISEASES OF THE NOSE AND THROAT. 

papillary hypertrophies. A genuine papilloma has definite histolog- 
ical characteristics which differentiate it positively from hypertrophy, 
or hyperplasia. Again simple varicosities, or vascular dilatations of 
the blood-vessels of the mucosa, have often been wrongly called 
" angiomata." In reading the descriptions of many cases of so- 
called " nasal fibroma " one cannot avoid the conviction that the 
tumors possessed a mixed character or were actually malignant. 
Moreover, some of these neoplasms originated in an accessory sinus 
or in adjacent structures and not in the nares, and hence cannot be 
properly classified as " nasal " fibromata. Those formidable cases 
in which occurs " frog-face " deformity from expansion of the nasal 
bones, and violent hemorrhages take place, both spontaneously and 
when attempts at removal of the neoplasm are undertaken, are prob- 
ably in this category and belong within the scope of general sur- 
gery. 

According to Lennox Browne the question of transformation of 
benign into malignant growth is settled in the affirmative. The tes- 
timony offered by one of his alleged cases, in which the patient him- 
self " attributed his trouble to the frequent and long-continued intro- 
duction of a Eustachian catheter " is certainly far from acceptable. 
This distinguished authority asserts that " sarcomatous degeneration 
is most commonly witnessed " while epitheliomatous transformation 
is more rare. He cites several cases supposed to be confirmatory. 
An interesting and curious case reported by Bayer in 1887 is more 
to the point. A villiform carcinoma was found implanted upon a 
base of innocent mucous polypoid tissue. Even in this case there 
remains a doubt as to which tissue was primary. A case of car- 
cinoma developing from a simple papilloma, under the observation 
of M. R. Ward, was proved by microscopic examination to be a 
genuine example of transformation. 

In a most interesting case of adenocarcinoma reported by F. E. 
Hopkins, there is reason to suspect that malignant transformation 
was provoked by violent manipulation, although the evidence is 
somewhat presumptive. It appears that on three occasions, at in- 
tervals of a year each, attempts had been made to remove supposed 
" myxomatous " tissue by forcibly dragging it out with polypus for- 
ceps. Symptoms of an intranasal growth had existed for many 



MALIGNANT DISEASE OF THE NASAL FOSS.E. I 63 

years and its benign character was inferred from the form, color and 
consistence of the neoplasm removed as well as from the fact that 
but slight hemorrhage followed the operation. No microscopic ex- 
amination was made at this time. In commenting on this case 
Jonathan Wright remarks upon the rarity of lesions of the kind and 
upon the rapidity of their evolution, adenocarcinoma being somewhat 
slower than pure carcinoma. He has collected twenty authentic 
cases, discarding those not supported by microscopic testimony, a 
lack of which applies to more than half of those in Bosworth's list, 
but including several, like that of Beaman Douglas, of possible extra- 
nasal origin. 

Whether we accept these unusual instances as authentic, or, with 
Billroth, look upon the whole matter as a " traditional myth," the 
occurrence is not so frequent as to deter us from interference in 
suitable cases. 



MALIGNANT DISEASE OF THE NOSE. 

Malignant disease may have its origin in the nasal fossa, but fre- 
quently begins in adjacent structures and gradually crowds into the 
cavity of the nose. Carcinoma, presenting in the form of epitheli- 
oma, is rather more frequent than sarcoma according to Bosworth's 
figures, but in the opinion of J. S. Gibb, who adds 70 cases of sar- 
coma and 48 of carcinoma, " primary carcinoma of the nasal cham- 
bers is undoubtedly rare," while sarcoma is believed to be more 
common than statistics would seem to indicate, many cases remain- 
ing unrecognized and more not being reported. The latter is usu- 
ally of the round-celled variety and may occur at any age. The 
former is seen seldom before middle life. Men are more prone to 
the disease than women. The starting point of the disease may 
be in the antrum, and as the growth progresses tumefaction of the 
face appears, accompanied by occlusion of the nostril from pressure 
upon the nasal wall of the antrum, or protrusion of the mass through 
the ostium maxillare. Pain may not be pronounced until the dis- 
ease is far advanced, but there is apt to be at an early period a 
bloody discharge from the affected nostril. Free and even fatal 
hemorrhage may occur. In a case of fibrosarcoma reported by the 



164 DISEASES OF THE NOSE AND THROAT. 

author several years ago the tumor grew in all directions, finally 
invading the cerebral fossa and causing total blindness. In the 
meantime the growth had extended to the pharynx and impeded res- 
piration. Previously on several occasions severe hemorrhage had 
taken place, spontaneously, and when attempts were made to clear 
the air track by snaring oft" portions of the tumor. At length, dur- 
ing a fit of wild delirium consequent upon cerebral irritation, the 
patient thrust his fingers in his mouth and dragged out a large piece 
of the growth hanging over the margin of the velum. Immediately 
there was a fierce gush of blood from the nose and mouth and in 
a few hours the patient succumbed. It was impossible to determine 
where the disease began, as it was first seen at a late stage and no 
autopsy was permitted. However, at a radical operation with 
removal of the upper jaw, undertaken by Weir several months before 
at the New York Hospital, it was found that the ethmoidal cells 
and the sphenoidal sinus were filled with neoplasm, the limits of 
which beyond could not be safely traced. In view of the uncer- 
tainty regarding the implantation of malignant tumors of the nose 
it is an open question whether all cases of this kind should not be 
referred to the general surgeon for radical operation. Piecemeal 
removal with forceps and snare is a superficial method which per- 
mits the base of the neoplasm to pursue its destructive invasion of 
adjacent parts. By many it is positively discountenanced (A. F. 
Plicque), while others are of the opinion that although no operation 
whatever is feasible in carcinoma, sarcoma is best treated by removal 
through the nose with the cold-wire snare (Bosworth). Of course 
the latter applies only when the disease is known to be strictly con- 
fined to the nasal chamber. In a case of this kind operated upon by 
Melville Black it was my privilege to watch the course of events 
several years subsequently. The growth involved the right middle 
turbinate and was removed with snare and forceps. Its sarcomatous 
nature was established by repeated microscopic examinations. 
About five years have elapsed without sign of recurrence. 

Implicit faith in the microscope as a guide in diagnosis is not 
advisable, at least as applied to sarcoma. A young woman once 
came to my clinic with stenosis of her right nostril. An extremely 
vascular tumor extending far back in the nostril was removed and 



MALIGNANT DISEASE OF THE NASAL FOSS.E. 1 65 

quickly recurred. Microscopic examination pronounced it a sar- 
coma and all preparations were made to expose and remove the neo- 
plasm by an excision of the upper jaw, when she called attention to 
a tumor over the crest of her tibia. Under rapidly increasing doses 
of potassium iodide the periosteal node and the nasal sarcoma (?) 
disappeared simultaneously. Such experiences should not discredit 
the microscope nor the examiner. Different sections of the same 
new growth may present totally different appearances, and it is often 
impossible to differentiate a small round-celled sarcoma from a 
syphiloma. They should rather teach us to be cautious in accepting 
testimony derived from a single source in cases of this kind. When 
there exists the least doubt as to the nature of a neoplasm a tenta- 
tive antisyphilitic course of treatment is always indicated. 

The difficulty in diagnosis is often vastly augmented, especially 
in elderly patients, by the concurrence of malignant disease and sim- 
ple mucous polypi. The presence of the latter may obscure the 
case until in the process of clearing out the polyps with the snare we 
may be startled by an alarming hemorrhage from an exceedingly 
sensitive growth, which proves to be malignant. Fetid discharge, 
hemorrhage and distortion of the face from intranasal pressure are 
seldom or never observed in gelatinous polypi and are invariably 
present earlier or later in malignant disease. 

In some cases neighboring bony tissues become affected. If the 
disease is located in the antrum the orbital plate is pushed up, forc- 
ing the eye from its socket, the skin of the face becomes adherent 
to the anterior wall of the antrum, which finally breaks down, per- 
mitting the protrusion of a fungous mass of vascular sensitive tissue. 
Cases which survive to this stage are most distressing from the dis- 
figurement, the pain and the insupportable fetor attending the pro- 
fuse ichorous discharge. The glands are seldom implicated. The 
development of epithelioma is much more insidious and rapid than 
that of sarcoma and may proceed without much pain or tumefaction 
until a late stage. Malignant disease may cause death by invasion 
of the cranial cavity, by exhaustion, hemorrhage, or metastasis, the 
last-mentioned being more frequent in sarcoma. The record of 
results of operative interference is not encouraging, at least when 
the disease is so extensive as to require an excision of the upper jaw. 



1 66 DISEASES OF THE NOSE AND THROAT. 

According to H. T. Butlin, whose researches on this subject have 
been most thorough, the chief operative dangers are from exhaus- 
tion, blood-poisoning and pulmonary complications. He believes 
that measures to secure a better showing are feasible, but, if not, that 
the operation should be condemned. Recurrence is almost inevita- 
ble, and in any case malignant disease of the nose must be regarded 
as one of the most formidable and intractable with which we have 
to deal. This discouraging view is in a measure refuted by the 
brilliant results secured by Abbe in several cases of malignant dis- 
ease which would ordinarily be regarded as inoperable. In one 
case in particular the right upper jaw and roof of mouth and part 
of the roof on the left side were removed, after a tracheotomy and 
ligation of both external carotids. This patient, a man 63 years 
old, was exempt from recurrence five and a half years after opera- 
tion, the effects of which, in part owing to a well-fitting plate, were 
scarcely perceptible. For details of the major operations the reader 
is referred to works on general surgery. In most cases we shall 
be called upon to rely solely on the free and constant use of ano- 
dynes. 

FOREIGN BODIES IN THE NASAL CHAMBERS. 

The introduction of a foreign body into the nose, either inten- 
tionally, accidentally, or in the act of vomiting, frequently occurs 
and may result in considerable disturbance. A one-sided purulent 
nasal discharge in a child is always suggestive of a foreign body. 
The objects children select are shoe-buttons, pebbles, or in fact any 
article small enough to be admitted to the anterior nares. 

As a rule, if no attempts have been made to extract the foreign 
body it will be found lodged well forward in the nasal fossa. In 
many cases it is retained for years and in the meantime the patient 
is supposed to be suffering from nasal catarrh. Usually a purulent 
discharge is the only symptom and frequently its character is so 
acrid as to produce more or less excoriation of the nostril and lip. 
The pressure of a foreign body may cause erosion of the mucous 
membrane with which it is in contact and occasionally perforation 
of the cartilaginous septum may result. In the event of laceration 
of the membrane the discharges show more or less admixture of 



RHINOLITHS. I 67 

blood. Syphilis may produce a one-sided nasal discharge but is 
attended by other symptoms which are confirmatory. Sinus disease 
generally causes discharge from one nostril but it is rarely observed 
in children and is seldom accompanied by obstruction to nasal breath- 
ing which is usually a prominent symptom of a foreign body. 

A definite diagnosis can be made only by inspection and sometimes 
by the use of the probe. It may be necessary to cleanse the parts 
thoroughly of secretion and to apply cocaine, and, in young children 
and in nervous subjects, a general anesthetic may be required. As a 
rule, foreign bodies are within reach and can be extracted readily 
by means of a nasal forceps. Sometimes a blunt hook, like a strabis- 
mus hook, may be passed behind the object and thus its removal 
effected. The loop of a cold-snare is sometimes found to be useful. 
If the foreign body has slipped or been displaced into the postnasal 
space it may be necessary to push it forward by means of the finger 
passed through the mouth behind the palate or it may be removed 
through the mouth. Sternutatories, the use of douches and the 
Politzer air-bag have been recommended for the removal of foreign 
bodies. The two latter methods are attended by more or less risk 
to the ears and, moreover, are less reliable than the nasal forceps. 
In rare cases in which the foreign body is of such a character as to 
imbibe moisture and increase in size after its introduction, or in 
cases in which it has become impacted, it may be necessary to do an 
external operation in order to secure more space for manipulation, 
or the object may have to be crushed and removed piecemeal. 

Many cases in which teeth have been found misplaced in a nasal 
fossa have been recorded. An interesting example noted by Krieg 
is that of a girl nineteen years old in whom the right external in- 
cisor " had lost its way upwards " and was seen impinging upon the 
border of the inferior turbinate. Extraction would of course be 
indicated provided any subjective disturbance results from the 



RHINOLITHS. 

A nasal calculus usually has a foreign body of some kind as a 
nucleus. A plug of inspissated mucus, or a coagulum, may furnish 
a base for the incrustation of salts, in which case the rhinolith, in 



1 68 DISEASES OF THE NOSE AND THROAT. 

its complete formation, would appear to be without a nucleus. The 
shape of these calculi corresponds closely to the conformation of the 
nasal fossa. Some of those on record reached a most enormous 
size. 

The causes which induce them are not clear. It would seem 
probable that some malformation of the nasal passages must be in 
part responsible for them, possibly in combination with some obscure 
change in the character of the nasal secretion. They are found to 
contain the ordinary ingredients of nasal mucus with a large pro- 
portion of organic material and, in some cases, a small quantity of 
iron. 

As a rule, the symptoms are those which naturally would be ex- 
cited by a foreign body. In some of the more remarkable cases on 
record the disturbances were very profound. Distortion of the nose 
and hard palate and even perforation of the palate at its junction 
with the velum, facial paralysis, and ocular disturbances may be 
enumerated. The discharge from the nose is almost always offen- 
sive, profuse and unilateral. 

The diagnosis is usually free from difficulty and may be estab- 
lished by inspection and the use of the probe. 

The treatment is similar to that of a foreign body, although a 
calculus may be too large to be removed entire and must be crushed 
beforehand. The density of the mass is sometimes so great as to 
make this by no means easy. A small lithotrite has been found use- 
ful for this purpose. 

EPISTAXIS. 

Nose-bleed may be traumatic, spontaneous or vicarious. Trau- 
matic nose-bleed may result from blows upon the external nose or 
from injuries to the mucous membrane from the introduction of 
foreign bodies, from violent blowing or sneezing, or from picking 
the nose. When the injury is of a serious character fracture of the 
nasal skeleton may involve the base of the skull and bleeding may 
arise from the ear as well as the nose, that from the latter being 
comparatively unimportant. In some cases the blood finds its way 
forward, but in young subjects or unconscious patients a consider- 
able quantity may flow backward and into the stomach, the persis- 



EPISTAXIS. 169 

tence of the bleeding being finally betrayed by the occurrence of 
hematemesis. In post-operative hemorrhages one knows where to 
look for the source of the bleeding; otherwise, it may be a matter 
of considerable difficulty to determine precisely its origin. 

Spontaneous nose-bleed may be symptomatic of an intranasal neo- 
plasm or it may occur in various constitutional conditions affecting 
the general circulation. It may be indicative of disease of the 
blood-vessels or of certain changes in the character of the blood 
itself which prevent coagulation. It is not uncommon in hemo- 
philia and several members of a family may habitually have nose- 
bleed. 

A sudden spontaneous nose-bleed in persons fifty years of age 
and upwards should always excite suspicion of cardiac or other 
organic disease. This form of epistaxis has been carefully studied 
by George Coates, who finds the occurrence preceded by long-con- 
tinued high arterial pressure and immediately by cardiac failure, 
either valvular or in the wall of the heart, accompanied by engorge- 
ment of the whole venous system. In these cases the indication is 
to relieve the turgid veins and the arterial pressure. After the capil- 
laries and arterioles have been dilated by agents like nitroglycerine, 
so-called heart tonics, strychnia and strophanthus, are useful. 
Plugging the nostril is seldom necessary and is generally futile, 
because the real difficulty is not in the nose, but yet it may have to 
be done as a last resort. 

A very rare variety of epistaxis associated with multiple telan- 
giectases of the skin and mucous membranes has been reported by 
William Osier. The angiomata were in various regions, but espe- 
cially on the face which they much disfigured. In one fatal case 
they were found in the mucous membrane of the stomach, as well 
as in the nose, and the nasal septum was marked by numerous dilated 
veins. A relationship between telangiectases and hepatic affections 
is suggested, and obviously local measures, so far as the hemorrhage 
from the nose is concerned, can have only a palliative and temporary 
effect. 

Vicarious epistaxis has been observed in women whose menses are 
suppressed and in functional uterine disease. Epistaxis is a com- 
mon symptom in many exanthemata and fevers and is especially 



170 



DISEASES OF THE NOSE AND THROAT. 



noted as an early symptom in typhoid. It is also a very frequent 
occurrence in diphtheria and is included among the symptoms of 
adenoids in the rhinopharynx. 

Fatal nose-bleed is an extremely rare accident and is hardly likely 
to occur except in hemophilia or in an individual already in a con- 
dition of extreme systemic depression. When confronted by a case 
of nose-bleed it is of the first importance to determine the source of 
the bleeding. It is not at all an unusual experience to meet with 
cases in which attempts to arrest the bleeding have been made by 
plugging the nostrils, whereas had the precaution been taken to de- 
termine the origin of the bleeding this disagreeable and somewhat 
dangerous process of plugging might have been avoided. In a very 





Fig. 65. Swolle: 



Frequent Source of Epistaxis. 



( Krieg. ) 



large proportion of cases a careful examination will discover that 
the blood- comes from a turgid granular turbinate body, or much more 
frequently from (Fig. 65) an eroded point on the septal cartilage 
within a very short distance of the anterior naris and above the floor 
of the nose. This is referred to by some writers as " Kiesselbach's 
spot," so named from an observer who has drawn especial attention 
to the small artery in this situation as a source of nasal hemorrhage 
(Fig. 66). Pressure exerted at that point fortified by the application 
of some styptic hardly ever fails promptly to control the bleeding. 
When the flow is very profuse, or is taking place in a patient nervous 
and frightened or young and obstreperous, it is no easy matter to 
keep the field clear long enough to discover the bleeding point; but, 
with a little patience, it is possible to see the blood ooze drop by drop 



EPISTAXIS. 171 

or, perhaps, in a distinct jet from the region referred to. In persons 
of advanced years with atheromatous arteries nose-bleed may be a 
conservative process and is not to be hastily checked. The loss of 
blood may be considerable without doing a very great amount of 
damage but, nevertheless, the alarm of the patient compels us to 
resort to a variety of measures for the purpose of checking the bleed- 
ing. Even if nothing were done in most cases a course of events 
similar to that observed in hemorrhage from other sources would 
doubtless ensue ; the bleeding would persist until the depletion began 
to produce a sensation of faintness when the diminished blood pres- 
sure would permit the formation of a coagulum to act as a natural 




Fig. 66. Dilated Vessels on Septum in Region known as " Hartmann- 
Kiesselbach " Spot. (Krieg.) 

tampon. Among the milder measures used may be mentioned, rais- 
ing the hands above the head, the application of ice, held in the 
mouth or placed in the nostril, or applied to the root of the nose 
either in the form of an ice-bag or gauze wrung out in iced water. 
In some cases hot water, at not less than 158 F., applied to the nos- 
tril seems to be effective, and this is certainly found to be an excel- 
lent way of stopping the hemorrhage which follows operative work, 
especially the operation for deviated septum. Hot water applied to 
the nape of the neck is said to have a decided effect. Various other 
domestic remedies have been used from time to time, but if these 
simpler methods do not avail and provided we cannot discover the 
isolated point of bleeding on the septum which has been described, 
plugging of the nostrils may be necessary. In the first place an 
attempt should be made to control the bleeding by plugging the ante- 



172 DISEASES OF THE NOSE AND THROAT. 

rior naris and this is best done by means of narrow strips of steril- 
ized gauze introduced far back in the nostril, successive layers being 
pushed in with a probe or nasal forceps. In order that packing from 
the front may be effective the gauze must not be more than half or 
three quarters of an inch wide, it must be carried as far back as 
possible and succeeding folds must be so small as to ensure a firm 
solid plug. The mistake is often made of attempting to put in too 
much at a time. This process is much simplified by the use of the 
Darmack packer, a metal canula through which the gauze is pushed 
by means of a rod or piston. The gauze may be dusted with tanno- 
gallic acid powder, or soaked in a saturated solution. After having 
packed in this way, if bleeding still persists and the blood finds its 
way back to the posterior naris, we shall be obliged to pack posteri- 
orly as well as in front. The introduction of the posterior nasal 
plug may be accomplished with Bellocq's canula (Fig. 67), or bet- 




»-tti' l |»«.ft.l<Hr'lfl.- 



D 



Fig. 67. Bellocq's Canula. 

ter a flexible catheter may be passed along the floor of the nose until 
its end appears in the oro-pharynx whence it may be drawn out 
through the mouth and a pledget of lint attached to it by a strong 
ligature. By pulling the catheter back again, the plug is drawn into 
the posterior naris, its passage being assisted by pressure from be- 
hind with the forefinger. It is important that the size of this plug 
should be correct ; if too small, it will be drawn into the nasal fossa ; 
if too large, it will become wedged between the velum and the 
pharynx and prove ineffective. Traction now being made on the 
ligature attached to the post-nasal plug, an anterior plug should be 
put in so as to completely fill the nasal fossa. The plug thus intro- 
duced should be removed not later than forty-eight hours ; if left in 
beyond that time it is apt to become a source of danger from decom- 
position. Before attempting to remove the plugs it is wise to soften 
them thoroughly by soaking with oil or fluid vaseline. The nasal 



EPISTAXIS. 



173 



hemostat of A. Cooper Rose consists of a hard-rubber tube covered 
with a soft-rubber bag which after its introduction is injected with 
air or water. It adapts itself to the irregularities of the walls of the 
nasal fossa in such a way as to exercise uniform pressure (Fig. 68). 
The withdrawal of the tube may be effected by turning a stop-cock 
at its end and allowing the air or water with which the bag is inflated 
to escape. A similar apparatus may be constructed out of a flexible 




Fig. 68. Cooper Rose's Nasal Hemostat. 

catheter covered by a rubber hood. In treating cases of epistaxis 
too much emphasis cannot be laid upon the desirability of avoiding 
the so-called styptics, especially the iron preparations. In severe 
cases they are not only ineffective but they produce a very disagree- 
able mess in the nasal fossa and, in all probability, the hemorrhage 
which they are able to control would cease spontaneously. Hemor- 
rhages of moderate severity may be checked by directing the patient 
to stand erect with both arms elevated above the head, in order to 
divert the blood pressure from the head to the upper extremities. 




Fig. 69. Simpson's Plug of Berxays' Compressed Cotton. 

If the bleeding comes from the septum pretty well forward simple 
pressure upon the ala of the nose with the head thrown slightly for- 
ward will control it. In mild cases a spray of peroxide of hydro- 
gen into the affected nostril will sometimes form a sufficiently firm 
coagulum to stop the bleeding. A very excellent way of controlling 
bleeding when situated well forward and near the floor of the nose 
is by the introduction of the nasal plug of Bernays' sponge (W. K. 
Simpson), a flat disk of compressed cotton which absorbs moisture 



174 DISEASES OF THE NOSE AND THROAT. 

and expands to about three times its original thickness (Fig. 69). 
The hemostatic power of suprarenal extract is very striking, whether 
used locally or internally. Even in cases of hemophilia it is said 
to have controlled a nose-bleed where other remedies had failed. It 
is important that fresh or aseptic solutions be used. Very unpleas- 
ant symptoms have followed the application of an infected solution. 
The following method of preparing a reliable solution is suggested 
by W. H. Bates. One part of powdered suprarenal is mixed with 
ten parts of boiling saturated solution of boracic acid. It is then 
filtered and should be boiled daily before use. Thus prepared it will 
retain its properties for months, although it is somewhat less effec- 
tive than a plain watery solution. Under the name " adrenalin " 
the blood pressure raising principle of the suprarenal gland is said 
to have been isolated in pure and stable form (Takamine). All the 
extraordinary effects observed from the use of the extract are pro- 
duced by this agent in vastly magnified degree. A. permanent steril- 
ized solution of adrenalin chloride, 1 to 1,000, is now being used 
diluted with distilled water or physiological salt solution, and if ex- 
perience substantiates all that is claimed for it we shall be in pos- 
session of the most valuable of recent additions to our pharmaco- 
peia. 

Attention has recently been called to a rare source of hemorrhage 
in epistaxis by Brown Kelly, who describes several illustrative cases, 
after a careful study of the etiology of this form of nose-bleed. The 
anterior ethmoidal veins, from which the blood comes in these cases, 
anastomose with the veins of the dura mater and with the superior 
longitudinal sinus. Their close connection with the intracranial 
veins, and the absence of valves in their walls may account for their 
tendency to bleed. The practical value of a recognition of this 
source of hemorrhage lies in the fact that the flow may be checked 
by firm plugging of the roof of the nose, leaving the lower part of 
the passage free for breathing. 

Whenever a localized hemorrhage can be defined, either from the 
septum, from the ethmoidal veins, or from an eroded turbinate body, 
it is better not to waste time by trying the various measures which 
have been described, but rather at once make direct pressure upon 
the spot from which the blood comes. An application of solid silver 



EPISTAXIS. 175 

nitrate, or better the electric cautery, is generally efficacious and is 
certainly most satisfactory as regards the comfort of the patient. 
It is necessary to dry the bleeding point as thoroughly as possible 
with sterilized cotton and be prepared to make the application in- 
stantly on withdrawal of the cotton. Thus it is certain that many 
patients may be saved the discomfort and danger of plugging, a dis- 
comfort often amounting to pain both at the time and subsequently, 
and a danger implicating especially the accessory sinuses and the 
ears. 

Without underestimating the significance of a nose-bleed it may 
be said that its importance is usually exaggerated and that most 
patients are unduly alarmed by its occurrence. 



CHAPTER VIII. 

SYPHILIS OF THE NASAL FOSS.E. LUPUS. TUBERCULOSIS. 
RHINOSCLEROMA. 

The primary lesion of acquired syphilis has been met with in sev- 
eral instances on record in the form of a small elevated papule soon 
undergoing ulceration which presents no special features by which 
it may be identified. A chronic indurated ulcer of the ala, of the 
turbinate body, or of the septum, accompanied by swelling of the 
submaxillary and sublingual glands, and a characteristic cutaneous 
eruption, is always open to suspicion. In the second stage of syphi- 
lis we meet with mucous patches and with ulcerative processes either 
superficial or deep ; in the latter case, the bone is apt to be affected 
and more or less extensive necrosis is followed by proportionate 
deformity. These deep ulcerations involving the framework of the 
nose are usually classed in the tertiary period and begin in the form 
of gummatous infiltration of the mucous membrane or as an inflam- 
mation of the bone or cartilage. In the former case the necrotic 
process in the hard parts is secondary to ulceration involving the 
mucosa and the periosteum or perichondrium. In the latter case 
death and destruction of bone or cartilage take place primarily and 
are followed by ulceration of the overlying mucous membrane. In 
some cases the affected bone instead of becoming necrosed and 
exfoliating undergoes a process of rarefying osteitis, or becomes so 
thickened as to obstruct the nasal passage, or, on the contrary, it 
may be absorbed. A syphilitic process sometimes invades a sinus, 
involves a nerve passing through one of the various foramina, or 
even extends to the meninges. 

Chancre and the early secondary lesions seldom require any spe- 
cial local treatment beyond cleanliness. They are usually painless 
and do not lead to extensive damage. The early recognition of 
gummatous infiltration in the nasal structures is of the utmost im- 
portance, not only because of the danger of delay to the integrity 
of the framework of the nose but also because the earlier constitu- 
te • 



SYPHILIS OF THE NASAL FOSSAE. 1 77 

tional treatment is begun the more prompt is the response. Usually 
the symptoms are those of ordinary coryza, and comprize sneezing-, 
lachrymation, headache, impeded breathing and loss of smell. The 
secretions are free and watery and on inspection the mucous mem- 
brane is seen to be red, swollen and may be edematous. In the 
majority of cases the septum is chiefly involved and may be thick- 
ened so as to cause more or less stenosis. On palpation with a 
probe the swelling is found to be less resistant and less hard than 
that of an ecchondrosis, or exostosis, but is sensitive and somewhat 
vascular. If the condition is not appreciated at this stage breaking 
down of tissue and the destruction of bone and cartilage will take 
place with surprising rapidity. In later stages we have presented the 
unmistakable odor of necrosis with profuse, bloody discharges which 
tend to inspissate and adhere to the ulcerated surface in the form of 
dark greenish-yellow scabs. Small " worm-eaten " sequestra may 
be extruded and if a probe be used the sensation of necrosed bone 
may be obtained. Generally when the vomer has been lost by this 
process the nose becomes flattened and widened and very character- 
istic facial disfigurement results, the so-called " saddle " nose. In 
some cases the external nose may be involved by the ulcerative 
process or perforation into the cerebral cavity may take place. 

The question as to the management of a nasal sequestrum resulting 
from syphilis is often presented and, in many cases, interference for 
removal of bone already dead and loose is permissible. As a rule, 
under active constitutional treatment a line of demarcation grad- 
ually forms and the bone affected becomes detached and may be 
removed without danger of damaging tissues that should be pre- 
served. In some cases, the sequestra are so voluminous that they 
cannot be extracted through the nasal passages and we are com- 
pelled to resort to the operation suggested by Rouge, which consists 
in separating the upper lip by incision along the gingivo-labial fur- 
row and throwing up the alae of the nose in such a way as to expose 
the nasal fossae. If necessary, the margins of the vestibule may be 
chipped with bone-forceps in order to give additional space. 
Although this operation appears formidable in reality it is found to 
be comparatively simple. The bleeding which occurs may generally 
be controlled by pressure and after removal of sequestra the parts are 
12 



1/8 DISEASES OF THE NOSE AND THROAT. 

simply replaced without the necessity of sutures or any special dress- 
ing. Various suggestions have been made looking to the correction 
of deformity resulting from syphilitic necrosis, among them the 
nasal support of vulcanized rubber, suggested by Bishop (Fig. 70), 
and the artificial bridge of platinum or aluminum in the form pro- 
posed by Martin and modified by Hopkins (Fig. 71). My own 
experience with these devices leads me to believe that nothing of 
the sort should be undertaken until the patient has been subjected to 
a long course of specific medication and we are assured that his 
tissues are in such a condition that they will repair themselves kindly 





Fig. 70. Bishop's Arti- Fig. ~i. Martin's Bridge 

ficial Nasal Bridge. Modified by Hopkins. 

after operative interference ; otherwise there is danger that the 
attempt to restore the contour of the nose may itself excite irritation 
and ulceration. The latter has happened in several instances in my 
own experience and a bridge has had to be removed, although, at 
first, the correction of the deformity was very gratifying and the 
apparatus gave no discomfort whatever. In its introduction the 
incision of Rouge is employed, the arms of the bridge, the shape 
and dimensions of which must be adapted to each individual case, 
being imbedded on either side in the superior maxilla. In certain 
cases, where the deformity is not extreme, it is found to be feasible 
to introduce a plate of platinum or celluloid underneath the skin, 
either by incision along the dorsum of the nose externally or by dis- 
section of the skin from the dorsum by means of a sharp pointed 
bistoury introduced through the nostril (Fig. 72), the plate being 



SYPHILIS OF THE NASAL FOSSAE. 



179 



pushed up into the pocket thus formed. In several cases in which 
is was necessary to remove a metallic plate the newly-formed con- 
nective tissue excited by its presence proved to give adequate support 
to a previously collapsed dorsum. 

For the correction of these deformities the subcutaneous injection 
of melted sterilized paraffin, which may be moulded to any desired 
form and in two or three months hardens to an almost cartilaginous 
consistency, has been practiced on the suggestion of Gersuny. 
Sunken parts may be thus supported to the proper extent and the 
tissues are expected to tolerate the presence of suitably prepared 




Fig. 72. Martin's Bridge in Position. 



paraffin much more kindly than they do a plate of metal. The expe- 
rience of A. Stein in one case of saddle nose and one of caries of the 
septum was most gratifying. He used paraffin melting at 48 to 
49 C. carefully sterilized. The so-called paraffin used by J. F. 
Lynch in a similar case was not the hard substance used in making 
candles but was a " white vaselin," which is quite soft at ordinary 
temperatures but is said to become firm after a time. The expe- 
rience of Delangre with suppuration in three out of seventeen cases 
in which paraffin had been injected for cosmetic or other effect in 



l8o DISEASES OF THE NOSE AND THROAT. 

various regions enforces the importance of strict observance of anti- 
septic details. Similar precaution is insisted upon by A. C. Heath, 
in whose case considerable local reaction followed the injection of a 
drachm and a half of paraffin, although the final result seems to have 
been fairly successful. It appears that the first to use solidifying 
oils under the skin was J. Leonard Corning, of New York, who 
injected a mixture of paraffin and cocoa butter not for cosmetic 
effect but for the purpose of immobilizing a muscle to prevent spas- 
modic contractions. Almost instant consolidation of the oil and pre- 
vention of embolism was ensured by spraying the injected area with 
ether. A mixture of the kind just mentioned would seem likely to 
provide more substantial support in nasal cases than a substance 
of semisolid consistence like " white vaselin," which must remain 
more or less fluid at the temperature of the body. It is equally 
important that the mixture should be thoroughly sterilized and that 
a combination of solid and fluid paraffin should be made giving a 
proper melting point (96.8 to 104 F.). If too high, it must be 
injected so hot and fluid as to involve the danger of causing local 
reaction and thrombosis : if too low the mass does not become solid 
enough to give support. To keep the mixture fluid during the pro- 
cess of injecting a syringe surrounded by a soft rubber sheath or 
hood as suggested by Eckstein, or by a hot water chamber like that 
proposed by Quinlan may be found useful. An electric coil might 
be applied to the barrel of the syringe perhaps more conveniently. 
A rather large needle should be used and care should be taken to 
introduce the paraffin in a steady current. In several cases treated in 
this way by Harmon Smith at the Manhattan Eye and Ear Hospital 
a melting point of no° was used and five minims of a four per cent. 
solution of cocaine were injected before the paraffin. There seem to 
have been no complications, and the results, while not perfect, were 
sufficiently good to encourage further experiment. His experience 
shows that it is better not to have the mixture too fluid, and by the 
use of a syringe of his own device, the piston of which is worked 
by a screw movement, it is possible to inject it in almost solid con- 
sistence (Fig. 73). It is asserted by A. I 1 .. Comstock and apparently 
proved by a series of interesting experiments that the mass becomes 
organized and actually traversed to some extent by fibrils of con- 



SYPHILIS OF THE NASAL FOSSAE. I 8 I 

nective tissue. This method is certainly quite promising and is much 
easier of application than the insertion of metallic supports. 

In many cases, however, loss of tissue and cicatricial contractions 
compel a resort to plastic surgery by the formation of flaps from the 
forehead, the cheeks, or other parts of the body. Nasal deformities 
due to syphilis are divided by Roberts into : ( I ) Those in which some 
part of the external nose has been ulcerated away; (2) those in 
which destruction of the septal cartilage has caused a transverse 
depression of the dorsum; (3) those in which in addition to the 



Fig. 73. Harmon Smith's Paraffin Syringe. 

sinking of the dorsum cicatricial retraction of the alae or tip of the 
nose is present. Those included in the first group are most easily 
remedied, but much may be done even after extensive loss of tissue 
by judicious, well-planned operations. Very often a great deal of 
patience and a long time are required to accomplish much, but in 
view of the repulsive deformity and the depressed mental state 
observed in these cases they certainly deserve careful study. The 
incisions in all rhinoplastic operations should be free enough to give 
a generous flap and to avoid tension, the resulting scars being much 
less disfiguring than the original unsightly deformity. 

In a few cases in which loss of tissue from specific disease has 
not been excessive the subcutaneous, or intranasal, operations de- 
scribed and very successfully practiced by J. O. Roe are applicable, 
but in the majority the destruction has been so extensive that not 
enough material can be found within the nose with which to build 
up a supporting framework. 

The constitutional treatment of syphilis of the nose is that of the 
disease in general. Progressive doses of a saturated solution of 
iodid of potash are given in milk or vichy, half an hour after meals, 
beginning with ten drops, a drop or more being added to each dose 
until we get evident signs of iodism or indications of an impression 



l82 DISEASES OF THE NOSE AND THROAT. 

upon the process going on in the nasal chambers. In the secondary 
and late lesions, especially if early treatment has been neglected, a 
combination of mercury with iodine is indicated, either in the form 
of the protoiodid, one sixth of a grain three times a day, by inunction, 
or by calomel fumigations. 

The use of alcohol should be prohibited, and the patient should 
be put upon full diet, instructed to get all the fresh air possible and 
to use locally a douche or spray of Dobell's solution or some similar 
detergent. In nursing infants the nasal obstruction may be a very 
serious matter. A few drops of adrenalin chlorid instilled into the 
nares will usually succeed in opening the air track, but it is clearly 
most important to get the patient under the influence of specific 
medication as rapidly as possible. In addition a tonic and suppor- 
tive treatment is often indicated. 



LUPUS AND TUBERCULOSIS. 

By many authorities lupus and tuberculosis are considered iden- 
tical, the former being looked upon as a modified or superficial 
variety of the latter. The appearance, clinical history and general 
tendency of these diseases differ sufficiently to justify a distinction, 
although it must be admitted that the nature of many cases is very 
doubtful. Many of their features are perplexingly similar, some 
resemble syphilis in certain points, while indications of mixed infec- 
tion are presented in a small proportion of cases. 

Lupus occurs in the form of small nodules which coalesce and 
ulcerate, or absorption may take place, a feeble tendency to repair 
appearing at the margins of the lesions (Fig. 74). The nodules are 
very hard and distinct, hyperemic at first and becoming paler until 
finally they break down and ulcerate. The lesion spreads in a pecu- 
liar serpiginous way supposed to be characteristic. It usually begins 
on the anterior part of the septum, thence extending to the alse and 
the skin of the face, the formation of new nodules and of a typical 
bluish cicatrix going on at the same time. Sometimes the process 
is reversed, the disease beginning in the integument. The bony 
structures are never involved but the cartilages occasionally are 
attacked. One or both nostrils may be affected and there is more or 



LUPUS AND TUBERCULOSIS OF THE NOSE. 1 83 

less stenosis. The discharges at first watery become thick and fetid 
as ulceration progresses, with tendency to crust-formation. Pain is 
usually complained of, and the nodules and ulcers are quite sensi- 
tive to the touch. Sometimes itching is a prominent symptom. The 
deformity resulting from absorption of nodules and consequent 
atrophy or from cicatricial contraction is often extreme. The dis- 







Fig. 74. Lupus of Anterior Nares (Gerber), showing lesions involving mucocu- 
taneous junction and attempts at repair. 

ease is very resistant to treatment, although cases of spontaneous 
recovery have been met with. 

Nasal tuberculosis is very rare. It may be primary but is usually 
secondary to manifestations elsewhere. It occurs in the form of 
nodules or tumors of variable size which ultimately undergo ulcera- 
tion (Fig. 75). The secretions are free, thick and offensive and may 
be tinged with blood. Unlike those of lupus the nodules of tuber- 
culosis are insensitive and pale in color, and the ulcerative process 



184 DISEASES OF THE NOSE AND THROAT. 

of the latter does not spread in a serpiginous way and shows no 
tendency to repair. The crucial test in diagnosis is the presence of 
the tubercle bacillus, the bacillus of Koch. It is hard to find in the 
scrapings but is pretty sure to be discovered in a section of a tuber- 
cular tumor, or nodule. General symptoms depend upon the activity 
and extent of coincident lesions in the lung or elsewhere. Anti- 
syphilitic treatment generally aggravates the local condition both 
in lupus and tuberculosis. If thought desirable the tuberculin test 
may be resorted to, a definite reaction generally being exhibited in 
cases of genuine tuberculosis, as well as in lupus. Its value in detect- 
ing latent or incipient cases or confirming suspicion in those giving 
no positive sign is unquestionable. Its use should be restricted to 





Fig. 75. Tuberculosis of Turbinates on Right Side and of Left Side of 
hi with Perforations. (Gerber.) 

cases of this class in which a diagnosis is of the utmost importance 
in order that measures may be taken to arrest the disease with some 
hope of success. Large -doses, which involve corresponding violent 
local reaction, are not required for this purpose. Proofs are abun- 
dant that the large doses once used encouraged dissemination of the 
bacilli by producing softening of the tubercular foci. But expe- 
rience with smaller quantities, two to five milligrammes, seems to 
have demonstrated its innocuousness, and its reliability for diagnostic 
purposes. 

The tubercular tumor which shows no inclination to ulcerate is 
apt to select as its site a turbinate body ; the tubercular ulcer, 
formed by the coalescence and breaking down of two or more miliary 
nodules generally begins at the anterior part of the septum whence 



RHINOSCXEROMA. 1 85 

it may extend to the external parts. Perforation of the septal car- 
tilage may take place. It would seem to be difficult to make a diag- 
nosis from the appearance of the ulcer which varies greatly in dif- 
ferent cases. It may be round or ovoid, its edges may be flat or 
elevated, its surface may be smooth, covered with grumous secre- 
tion, dotted here and there with caseating tubercles, or obscured by 
masses of exuberant granulation. 

The treatment of lupus and of tuberculosis should be conducted 
on similar lines. After careful cleansing of the parts all morbid 
deposit should be thoroughly removed by means of the curette and 
the exposed area is then rubbed with pure lactic acid. The parts 
must be kept scrupulously clean with Dobell's solution or a carbolized 
alkaline wash, and if reaction and pain are excessive the surfaces 
may be coated with an emollient ointment. One of the best is a mix- 
ture of orthoform with albolene or lanolin, a drachm to the ounce. 
General medication must be resorted to according to indications. 
In tuberculosis, as a rule, we are dealing, not with a local disease, 
but with a general diathesis, and the importance of good hygiene, 
pure air and sunshine, nutritious diet and supportive treatment is 
beyond question. 

It seems to be clearly proven that tubercle bacilli may be found in 
the nasal fossae of the perfectly healthy but especially of those atten- 
dant upon tubercular subjects, hence the necessity of care to avoid 
producing abrasion of the nasal mucosa through which the germ 
might find entrance to the system. 



RHINOSCLEROMA. 

The opportunity of studying rhinoscleroma in this country is 
extremely rare. In 1893 Jackson could discover only three reported 
cases. Since then a few have been added to the list, with one excep- 
tion having been imported from abroad. This disease was first 
described by Hebra, whose account in some particulars is still ac- 
cepted as correct. It is a chronic inflammatory process involving 
the mucous membrane of the upper air track, usually beginning in 
the nose at the anterior part of the septum, and sometimes extending 
thence to the pharynx, larynx and even to the trachea. It is char- 



1 86 DISEASES OF THE NOSE AND THROAT. 

acterized by extreme thickening and ivory-like hardness of the 
affected parts, which are sensitive to the touch but are free from 
spontaneous pain. It develops very slowly without edema or acute 
symptoms. It eventually causes great external deformity as well 
as internal distortion from cicatricial retraction and gradual filling 
of the passages with indurated masses. The tip of the nose becomes 
enormously broadened, hard and lobulated. When the pharynx is 
invaded the palate is thickened, leathery and covered with fine scales. 
The smooth nodular appearance of the external nose is compared 
by Kaposi to that of keloid. In some cases the course of the disease 
is reversed and it appears on the palate, in the larynx, or even in the 
trachea before any signs are present in the nares. The evidence 
seems to be almost convincing that a rare lesion described as chorditis 
hypertrophica chronica inferior and what is known as Stoerk's blen- 
orrhea are identical with rhinoscleroma. This view is held by Freu- 
denthal, who has given a very careful and complete report of a case 
under his observation. The typical bacterium of rhinoscleroma is 
said to be the capsule bacillus of Frisch, resembling the pneumo- 
coccus of Friedlander, but not easily demonstrable. In a case re- 
ported by Roe, which is said to be the first instance of the disease 
originating in this country, it was difficult to find the bacilli in the 
cells, although certain bacilli were cultivated not unlike the pneu- 
mococcus. 

The treatment of the condition appears to be very unsatisfactory. 
The morbid tissue may be removed by the knife, or by curetting, or 
may be destroyed with the galvanocautery. Various chemical caus- 
tics, especially lactic acid, have been tried, with only temporary 
amelioration. Internal medication makes no impression on the lesion. 
In some cases the nodules soften and break down, as in one reported 
by C. W. Allen, in which almost the entire mass sloughed away, 
exposing the bones of the upper jaw and the nasal septum. Gener- 
ally the disease is extremely chronic, although the duration of Roe's 
case was only three and a half years. Its resemblance to malignant 
disease and the fact that the nose is often not its primary site have 
suggested the propriety of substituting the name " granulation sar- 
coma," or a similar title, for rhinoscleroma, which latter is manifestly 
inappropriate. In this connection Freudenthal suggests that good 



RHINOSCLEROMA. 1 87 

results may be possible with injections of Coley's fluid as in sarcoma, 
and he refers to the favorable reports of Pawlowsky with injections 
of rhino sclerene. In one case, that of Lubliner, the lesion absolutely 
disappeared after an attack of typhoid fever. 



CHAPTER IX. 

NASAL NEUROSES. HAY FEVER. NASAL HYDRORRHEA. 

Neurotic disturbances met with in the nose may affect the special 
sense of smell, or the secreting function of the mucous glands, or 
may excite certain reflex phenomena. 

Parosmia is a perversion of the sense of smell in which the subject 
perceives odors which do not exist. When the odor is offensive the 
term kakosmia is applied. It may be due to a pathological change 
in the nerve terminations or to some central nerve lesion. This phe- 
nomenon has been met with as a precursor of insanity and in the 
course of syphilis, hysteria and epilepsy. 

An exaggerated sense of smell, or hyperosmia, is met with in con- 
ditions of neurasthenia and in hysteria as well as in certain sexual 
derangements in women. 

Anosmia, or loss of smell, may be partial or complete and may 
result from injury or disease affecting the olfactory nerve or the 
nerve centers in the brain. It may be the result of some peripheral 
irritation, such as pungent gases or strong local applications to the 
nasal mucous membrane might produce. The sense of smell is also 
lost or impaired in simple acute and chronic inflammatory condi- 
tions, as a sequel of grip, and sometimes in connection with adenoids 
and polypi, or other lesions causing nasal obstruction. Finally loss 
of the sense of smell may be referred to functional or reflex disturb- 
ances. Thus anosmia may be divided into three classes (Onodi). 
(i) Essential or true anosmia, central or peripheral, depending on 
the part of the olfactory nerve affected; (2) mechanical or respira- 
tory anosmia resulting from atresia of the nares, congenital or 
acquired. Under this head are included conditions which prevent 
access of air to the nasal chambers, such as deformities, new growths 
and inflammatory swellings; (3) functional anosmia, as in hysteria, 
and as a reflex from ovarian or uterine disturbance, from psoriasis 
buccalis, and from cauterization of the inferior turbinates. 

188 



NASAL NEUROSES. I 89 

The prognosis of anosmia depends in great degree upon its cause. 
Many cases even of long standing are benefited by treatment, espe- 
cially when the condition is a sequel of influenza or neurasthenia. 
In advanced atrophy of the nasal mucous membrane the loss of smell 
is usually complete and permanent. 

Local treatment should be conducted with caution. In the first 
variety the mode of treatment is governed by the cause and its loca- 
tion. The relief of mechanical anosmia is generally feasible by 
removing the nasal impediment. In functional anosmia stimulation 
of the olfactory tract with galvanism and the internal use of general 
tonics are sometimes effective. 



HAY FEVER. 

Since the subject of reflex neuroses was first brought up an im- 
mense number of affections have been traced to disease of the nasal 
chambers. It must be admitted that many of these relationships have 
their origin in the imagination of the observer. In other words, a 
genuine nasal reflex is relatively rare. The typical, most familiar 
example of a nasal neurosis is hay fever, at times accompanied by 
reflex asthma. It is otherwise known as hyperesthetic rhinitis, or 
periodical vaso-motor rhinitis, as well as by other titles. Three con- 
ditions seem to be essential to its development, the neurotic tempera- 
ment, nasal hyperesthesia associated or not with a deformity or 
neoplasm of the intra-nasal structures and, finally, an exciting cause 
in the shape of some irritant, either pollen, or emanations of some 
kind, animal or vegetable, or certain peculiar atmospheric states. It 
is allied in many of its features to other neurotic disturbances, par- 
oxysmal sneezing and similar phenomena known as autumnal catarrh 
and rose cold. These occur independently of any special period 
of the year and are sometimes known as pseudo-hay fever. Rose 
cold is so called from its occurrence in June, the month of roses, 
although the attacks are not limited to that period. It is a well 
known fact that sneezing, cough, and lachrymation may be caused 
by irritation of certain areas in the nasal mucous membrane. It is 
possible to demonstrate with a probe sensitive regions but the idea 
that thev are always to be found in similar situations in all indi- 



I9O DISEASES OF THE XOSE AND THROAT. 

viduals is erroneous. The influence of heredity as a predisposing 
cause is unquestioned ; in at least half the cases of hay fever we suc- 
ceed in getting a history of some neurotic manifestation in other 
members of the family. It is a curious fact that the disease seems 
to be limited to the Anglo-Saxon race and it is said to be more prev- 
alent in males than in females. It is not always easy to discover 
the irritant which excites an attack. Dust of any kind, tobacco 
smoke, pollen of various plants, as rag-weed, or golden-rod, and 
emanations from certain animals are capable of producing it. The 
name rose cold is derived from the fact that symptoms of this kind 
are induced by roses, but the famous case of J. N. Mackenzie in 
which characteristic attacks were caused by an artificial rose proves 
that the phenomena may be of purely psychical origin. Many inter- 
esting cases are on record in which attacks closely resembling hay 
fever have developed in connection with renal irritation. Paroxys- 
mal coryza of nephritic origin subsides with the relief of urinary 
symptoms and is not periodic, but recurs if for any cause the renal 
derangement becomes aggravated. 

Haig, Bishop and others who have made extensive study of this 
subject, attribute hay fever to an excess of uric acid in the fluids of 
the body. Daly, Bosworth and others profess to find invariably some 
intranasal abnormality which acts as an exciting cause. Price- 
Brown traces the outbreaks to an antecedent hypertrophic rhinitis. 
Excessive alkalinity of the nasal secretions is thought to explain 
the condition in some cases. The argument in support of the uric 
acid as well as of the nasal stenosis theory of causation is measurably 
weakened by the fact that these states are very prevalent in those 
without a suspicion of hay fever. That they often coexist admits of 
no question ; that they are occasional excitants is very probable. An 
attack is sometimes provoked by indiscretion in diet and consequent 
digestive derangement. Extraordinary mental emotion or nervous 
excitement will aggravate or may even induce an attack. Certain 
localities seem to be relatively free from the disease and yet some 
suffer where others are exempt, and again the latter may succumb in 
a region where they have previously escaped. Hay fever usually 
occurs in adolescence or early middle life, but has been observed in 
children and even in infants. It is essentially a disease of the well- 



HAY FEVER. I9I 

to-do, or at least of those whose affairs involve more or less nerve 
tension and excitement. Yet not a few cases have come to my notice 
in those whose lives were placid and free from care, but such persons 
have usually given a highly neurotic individual or family history. 

The symptoms of hay fever vary somewhat in different individuals 
and in the time when they appear. Usually the attack begins early in 
August and ceases with the advent of frost or cold weather. In 
some seasons the outbreak may be delayed and occasionally its dura- 
tion is abbreviated, whence the inference that atmospheric states may 
have some influence. One of the earliest symptoms is a sensation 
of itching and burning of the eyelids, particularly at the inner can- 
thus. Sometimes there is decided itching in the pharynx or roof 
of the mouth. This may persist for hours or days and is accom- 
panied by sneezing and suffusion of the eyes. The attack may come 
on with great abruptness or by degrees. Stenosis of the nostrils 
results from turbinate turgescence and presently a serous discharge 
begins which soon becomes remarkably free. Mental as well as 
physical depression, especially in very neurotic subjects, may be pro- 
nounced. The eyelids frequently become very much swollen and 
there may be marked photophobia. In some cases asthma super- 
venes, resembling, in all respects, the ordinary attacks of this affec- 
tion. Examination of the nose may show nothing more than would 
be expected in the early stage of acute catarrhal rhinitis, but the 
membranes are much less injected or are actually pale and soggy in 
appearance, and the serous effusion is much more abundant. In the 
interval of health nothing abnormal may be found in the nose, or 
some deformity may be discovered which may be reasonably looked 
upon as an aggravation if not the cause of symptoms. 

The prognosis as to the attacks is favorable ; so far as the cure of 
the disease or the tendency to it is concerned, we cannot speak so 
hopefully except possibly in those cases in which we are able to 
discover a positive nasal lesion. The prognosis when little or no 
structural change can be detected and in individuals of highly neu- 
rotic temperament is decidedly less favorable. 

In any case we are justified in promising some degree of ameliora- 
tion of symptoms as a result of treatment. Many patients will pre- 
fer to secure exemption from the trouble by resorting to localities 



I92 DISEASES OF THE NOSE AND THROAT. 

where experience has taught that they may be reasonably free from 
disturbance. A sea voyage will sometimes afford escape. A resi- 
dence at a moderately high altitude appears to give immunity to 
some. The use of nerve tonics and sedatives is considered of value, 
and stimulants give temporary relief, but their use is not to be 
advised except in extreme cases. 

The importance of internal medication is urged by adherents of 
the uric acid theory as well as by many of those who find the first 
cause of hay fever in the nasal fossae. Without doubt cures have 
followed correction of nasal anomalies, yet the attention given to 
hygiene, diet, exercise and clothing, not to mention the use of tonics, 
by most practitioners shows that the sole reliance is not placed upon 
local treatment. Bishop, who is a stout advocate of the uric acid 
idea, gives the acid phosphates (Horsford) in one or two teaspoon- 
ful doses night and morning, and never fails to stop an attack by 
a combination of atropia and morphia in suitable cases, one part of 
the former to fifty of the latter, one sixteenth to one eighth of a 
grain of this mixture being given to an adult. Atropine has always 
been well thought of in asthma and seems to be especially adapted 
to that associated with hay fever. In extreme cases the addition of 
morphine may be desirable, but the use of such drugs should never 
be left to the discretion of the patient. Iodide of potassium, or 
sodium, or syrup of hydriodic acid finds favor with some, while oth- 
ers recommend strychnia in full doses, or the three valerianates of 
zinc, iron and quinine, one grain each. It is apparent that we have 
no specific for hay fever and in many cases the administration of 
drugs does more harm than good. In the presence of symptoms of 
anemia or of asthmatic attacks we may expect the best results from 
internal medication. 

In these days when the accessory sinuses are attracting so much 
attention perhaps it is not surprising that they should be accused of 
joining the hay fever conspiracy. Accordingly we find E. Fink 
protesting that the sinuses, and especially the antrum, provide the 
secretion which is one of the prominent features of the disease. In- 
sufflations of aristol made through the ostium are said to cure the 
most obstinate case. A degree of suspicion is thrown on the gen- 
uineness of this contention by the earnestness with which treatment 
of the coincident neurasthenia is urgfed. 



HAY FEVER. I 93 

Of local remedies nothing- gives an equal degree of immediate com- 
fort as cocaine applied to the mucous membrane of the nose on a 
pledget of lint or in the form of a spray. It should never be en- 
trusted to a patient, and when a strength greater than four per cent, 
is required for the desired effect a detrimental impression upon the 
nervous system is almost inevitable so that its advantages seem to 
be more than overbalanced. Moreover, its action is so transient 
that we are forced to conclude that its indiscriminate recommenda- 
tion is not justifiable. The evils of the cocaine habit, a risk not to 
be ignored, are unhappily familiar. Great hopes have been enter- 
tained as to the value of a recent addition to the pharmacopeia in 
the suprarenal extract. So far as observations have gone it seems 
to modify the symptoms, and hitherto no bad effects have been ob- 
served. Yet it is still on trial and no final conclusion as to its per- 
manent value is permissible. 

The aqueous extract of the suprarenal gland possesses astringent 
and hemostatic qualities, and is, at the same time, a tonic to muscle 
fiber. A great advantage of the drug is that it is non-toxic and may 
be used liberally without detrimental effects. Not only is it free 
from toxic properties itself, but it seems to possess the power of 
limiting the toxic effects of cocaine with which it may be used in 
combination or alternately. It apparently contracts the blood-vessels 
and thus retains the cocaine in the tissues, prolonging its anesthetic 
effect. The difficulty hitherto has been to secure a stable solution 
especially in warm weather; decomposition takes place rapidly and 
a solution, although retaining its peculiar blanching properties, be- 
comes irritating and unfit for use. It is found that glycerine in ten 
to twenty-five per cent, solution will prevent putrefaction for several 
days. The limit of solubility in water is about fifteen grains to the 
drachm. 

A formula for a permanent solution which may be kept for sev- 
eral months is thus given (L. S. Sommers) : 

Adrenal 20 grains. 

Phenic acid 2 grains. 

Beta-eucain 5 grains. 

Distilled water 2 drachms. 

M. Macerate for ten minutes and filter. 
13 



194 DISEASES OF THE NOSE AND THROAT. 

The effect of the solution upon the mucous membrane is apparent 
almost at once and reaches its maximum in from three to five min- 
utes. The formula just given may be used without the eucaine. It 
causes slight smarting which soon subsides. Retraction of the 
swollen turbinates is almost immediate and lasts several hours. In 
moderate cases it is not unusual to see a single application give per- 
manent relief. More immediate and pronounced results are claimed 
by some if the adrenal be given internally as well as used locally. 
One grain of the powder, representing eight grains of the fresh 
suprarenal gland, may be given in tablet or capsule every two hours, 
until dizziness, or cardiac palpitation, develops, or the nasal mucosa 
shows the characteristic effects of the drug. For local use the fol- 
lowing solution, said to be permanent, may be applied in spray or on 
cotton (E. F. Ingals) : 

Suprarenal capsule 15 grains. 

Boric acid 4 grains. 

Cinnamon water 1 drachm. 

Camphor water, hot 2 drachms. 

Boiling water q.s. ad 4 drachms. 

S. Macerate four hours and filter. 

A one per cent, aqueous solution of resorcin is said by Oppen- 
heimer to be an almost perfect preservative. 

A solution of suprarenal extract with chloretone, recently intro- 
duced, is fairly permanent and as active as a freshly prepared solu- 
tion of the dried gland. Each minim represents one grain of fresh 
gland and the mixture contains 0.8 per cent, of chloretone. The 
combination of hemostatic, anesthetic and antiseptic properties thus 
formed promises to be valuable. Adrenalin chloride mentioned in 
the chapter on Epistaxis has similar efficacy and is a more stable 
preparation. During the paroxysms of hay fever more or less com- 
fort is derived from inhalations of camphor and menthol, equal 
parts in an inhaler, or in albolene solution so mild as to be quite 
free from irritating effects. 

In a small proportion of cases a weak solution of chromic acid, 
Y% of a grain or less to the ounce of water, has been found efficacious 
in hay fever (Macdonald). A combination of muriate of quinine, 
1 drachm, glycerite of carbolic acid, B. P., 1 ounce, and perchloride 



HAY FEVER. 1 95 

of mercury, 1/1000 part (Andrew Clark), is useful in cases exhibit- 
ing no structural change, but the application is more or less painful 
and excites disturbance resembling a violent attack of hay fever 
which lasts a day or two. It is customary to cleanse the nostrils 
thoroughly, spray with cocaine in 10 per cent, solution, and then 
paint the mucous membrane of the nasal fossse with Clark's solution. 
Considerable burning is caused in spite of the cocaine, and for the 
next twenty-four or forty-eight hours a violent attack of coryza 
occurs. 

In cases accompanied by structural anomalies or new growths it is 
possible to accomplish much more definite results than in others, in 
which only the remedies just described are applicable. Ecchon- 
droses and exostoses of the septum impinging upon a turbinate are 
found to act as exciting causes. Hyperplasia of the turbinate tissue 
in contact with the septum is productive of similar results. Nasal 
polypi are well known to be sources of irritation, and the removal 
of these various abnormalities is almost always followed by some 
improvement if not an absolute cure. Sensitive spots, identified by 
exploration with the probe, either upon the septum or the turbinate 
bodies, may be destroyed by the galvano-cautery or chemical caus- 
tics. 

The observation that the internal use of ipecac prevents the local 
effects of this drug produced in certain individuals has led to experi- 
ments with plants known to cause similar disturbances, especially 
the rag-weed (Holbrook Curtis). Some very curious results are 
recorded with tinctures and fluid extracts of golden-rod, lily of the 
valley and other plants. A solution representing in each drachm 
five minims of the fluid extract of Ambrosia artemisia is recom- 
mended to be given between meals and at bed-time two weeks before 
the hay fever is expected, the dose to be increased to the point of 
tolerance during the attack. My own experience with it thus far 
has not been such as to justify any confidence. In a few cases in 
which a favorable report was made it seemed to be necessary to 
eliminate the credulity and the faulty observation of the patient. 

The tendency to attacks of hay fever and their severity seem to 
diminish with advancing years, and if immunity for several suc- 
cessive seasons can be obtained, if the nasal membranes can be re- 



I96 DISEASES OF THE NOSE AND THROAT. 

stored to a condition of health and if, at the same time, the neurotic 
disposition can be modified we may hope for a disappearance or a 
mitigation of the disease. The prominence of the neurotic element 
varies greatly in different cases and in the same case in different 
seasons, but is never absent. It is rather more pronounced in cases 
of paroxysmal sneezing than in other neuroses. In some individuals 
attacks of sneezing occur on rising in the morning, on sudden ex- 
posure to bright sunshine, or after the ingestion of a hearty meal. 
A cure of these cases has been accomplished by hypnotic suggestion. 
Not every one is amenable to hypnosis, yet, contrary to the general 
belief that hypnotism is applicable only to " fools and weaklings," 
the experience of Lloyd Tuckey shows that " strong, muscular and 
intelligent men and women " are the best subjects. In many cases, 
however, a nasal lesion must be removed in order to obtain a per- 
manent cure. 

In spite of all that can be done the melancholy spectacle is all too 
frequent of an individual who has exhausted the resources of the 
general practitioner, who has experimented with every known quack 
nostrum, who has had most of his original intranasal structures re- 
moved by the ardent rhinologist and who still remains the unhappy 
victim of hay fever. 

NASAL HYDRORRHEA. 

A flow of watery secretion from the anterior nares under the name 
of nasal hydrorrhea is looked upon by some authorities as a modified 
form of hay fever. It occurs independently of season and is, un- 
doubtedly, a vaso-motor affection. In some cases on record it seems 
to have been of malarial origin, occurring periodically, and accom- 
panied by chills and fever, a cure resulting from the administration 
of quinine. The few cases reported show great variation in clinical 
history, nasal discharge being the only fixed symptom. The quan- 
tity of secretion is more or less abundant, even a pint or more of 
fluid escaping in twenty-four hours, sometimes from one and again 
from both nostrils. It seems to have been observed in one instance 
as a symptom of general edema, in other cases associated with 
cerebral disease, and it has been seen in hysterical patients. Lhider 



NASAL HYDRORRHEA. I 97 

these circumstances it is, of course, merely a symptom; in other 
cases the hydrorrhea is so pronounced as practically to constitute in 
itself a disease. A serous secretion from the nostril in nasal polypi 
and in polypi of the accessory sinuses is very common, but under 
these circumstances must be placed in another category. In con- 
nection with trifacial neuralgia and certain genito-urinary distur- 
bances in either sex it must be regarded as purely a reflex disorder. 
The subjects of this affection are very sensitive to atmospheric con- 
ditions and the discharge is usually preceded by sensations of tickling 
in the nostrils and attacks of sneezing. 

It is usually met with in adults, the case reported by Cathcart in 
a girl nine years old being quite exceptional. 

Examination of the nose shows turgescence of the mucous mem- 
brane, which may be redder than normal and is bathed in watery 
secretion. In cases of long standing the membranes become some- 
what pale. There may be considerable nasal stenosis and paroxysms 
of reflex asthma may occur. 

Looking upon the affection as a symptom of a general diathesis 
it is obvious that local treatment alone cannot be efficacious. In 
view of the evidence of a malarial element the use of quinine is al- 
ways indicated. Mustard foot baths with atropine and morphine 
internally have been known to check an attack. Violent local meas- 
ures should be avoided, but relief may be obtained from applications 
of menthol in albolene or, if distress is extreme, by the use of cocaine. 
A more prolonged effect from adrenalin has been claimed in some 
cases, while in others it has utterly failed. Decortication of the nasal 
mucous membrane recommended by Moure and daily massage of the 
nasal fossae with cotton tampons soaked in borated vaseline and con- 
taining a little cocaine advised by Jankelevitch may be resorted to 
in the failure of other measures. The internal use of strychnin, 
hydrotherapy and the external application of the continuous electric 
current have each been found beneficial. Applications of hot air, as 
described in the chapter on Rhinitis, have been effective in the hands 
of G. Mahu, who seems to have observed an extraordinary number 
of these cases. 

This condition must not be mistaken for the very rare phe- 
nomenon which has been the subject of recent study, namely, 



I98 DISEASES OF THE NOSE AND THROAT. 

the spontaneous discharge of cerebro-spinal fluid from the nose. 
Undoubtedly some of the latter have been reported as cases of nasal 
hydrorrhea, but it is very clear that they have no similarity and that 
the affection about to be considered has no relationship with hay 
fever. One of the earliest cases described was in a girl of fifteen 
who had hydrocephalus from birth (Leber). She had severe head- 
aches, dizziness, and impaired vision and, finally, an epileptic fit 
which was followed by the continuous escape of fluid from the left 
nostril. 

In another case intermittent discharges from the nose were pre- 
ceded by severe headache, chiefly over the left eye, top and back of 
the head. When the flow was established the patient was relieved 
and appeared to be in perfect health in other respects (St. Clair 
Thomson). 

In one case the discharge of watery fluid was preceded by very 
grave cerebral disturbance indicative of pressure as shown by the 
existence of optic neuritis and the occurrence of symptoms of tumor 
of the brain (Freudenthal). The flow was continuous night and 
day, in this respect differing from that of nasal hydrorrhea which 
usually stops at night. In the chemical analysis of the fluid, how- 
ever, we have a pretty definite means of differentiating these condi- 
tions. The chief points which serve to identify cerebro-spinal fluid 
are first, its clear watery character ; second, its low specific gravity ; 
third, the small amount of proteid in it and the absence of albumin, 
and fourth, the presence of a substance " possibly related to pyro- 
catechin which reduces Fehling's solution but is not dextrose." The 
history of these cases shows the importance of avoiding measures 
intended to check the flow, since cerebral symptoms recur almost as 
soon as any obstacle is offered to the escape of the fluid. It is re- 
markable that the leakage may continue indefinitely without any 
marked impairment of the general health. 



THE PHARYNX. 

CHAPTER X. 

ANATOMY AND PHYSIOLOGY OF THE PHARYNX. 

The pharynx extends from the posterior nares to the cricoid car- 
tilage and is divided into three portions, the upper, or rhino pharynx, 
ending at the level of the palate, the middle, or oropharynx, extend- 
ing to the vestibule of the larynx, and the lower, or laryngo pharynx , 
opening into the esophagus at the lower border of the cricoid car- 
tilage. 

The superior division has opening into it the orifices of the poste- 
rior nares, or choanse, those of the Eustachian tube on either side and 
below it is continuous with the buccal pharynx. Lesions in this 
division of the pharynx are of special interest from their relation to 
the Eustachian tubes, the sphenoidal sinus and the posterior nares. 
The orifice of the tube on either side is on a line with the inferior 
turbinate body and between them is sometimes found a mass of 
lymphoid tissue called the Eustachian or tubal tonsil. It is generally 
continuous with other adenoid vegetations on the wall of the rhino- 
pharynx and hardly deserves an independent name. The posterior 
lip or margin of the Eustachian tube is much more prominent than 
the anterior and forms a decided eminence called the Eustachian 
cushion. Behind it is a depression of considerable depth, the fossa 
of Rosenmuller, where large quantities of adenoids often accumulate 
and their removal with a large sharp-edged instrument is attended 
by some risk to the cushion. 

The middle division of the pharynx, or oropharynx, contains ag- 
gregations of lymphoid tissue between the pillars of the fauces known 
as the palatal or faucial tonsils, and similar masses at the base of the 
tongue called the lingual tonsil. The former present pathological 
conditions of great importance in both an acute and a chronic form. 
Acute disturbances of the lingual tonsil are less common, but the 

199 



200 DISEASES OF THE XOSE AND THROAT. 

latter lymphoid mass often undergoes considerable enlargement and 
becomes a source of functional derangement affecting the pharynx 
and the larynx. The lingual tonsil also at times is involved in phleg- 
monous inflammation. Cases reported as abscess of the tongue are 
doubtless often a suppurative inflammation involving this structure. 
Across the base of the tongue we also see, especially in adults, a 
varicose condition of the blood-vessels quite independent of any spe- 
cial or marked change in the lymphoid tissue. An interesting and 
curious phenomenon at the posterior vail of the pharynx, visible 
through the mouth in the form of a pulsating vessel, has lately at- 
tracted a good deal of attention. It seems to have no special sig- 
nificance and is unimportant except when we may be called upon to 
use the knife in this region. 

The laryngo-pharynx, the third division, is of special interest to 
the laryngologist in connection with foreign bodies, which are apt to 
lodge at the point where the pharynx merges into the esophagus, 
and in connection with neoplastic formations invading it from the 
larynx. Many cases of dysphagia, or odynphagia, have their origin 
not in the swallowing track, but in the laryngeal cavity where com- 
pression by the inferior constrictor causes a feeling of obstruction or 
a sensation of pain. 

The pharynx measures from above downward about four and a 
half inches. Its narrowest portion is at its junction with the esoph- 
agus. Its lateral diameter is greater than its anteroposterior, being 
widest on a level with the cornua of the hyoid bone. Its wall is com- 
posed of a fibrous coat, the pharyngeal aponeurosis, which is lined 
by mucous membrane and surrounded by muscles, the pharyngeal 
constrictors. 

The pharyngeal aponeurosis is best marked at its upper portion 
where it is attached to the posterior part of the body of the sphenoid 
bone in front of the pharyngeal tubercle. Thence it runs outwards 
to the apex of the petrous portion of the temporal bone to the car- 
tilage between it and the occipital bone to the Eustachian tube and 
the internal pterygoid plate. 

The mucous membrane is closely adherent to the base of the skull ; 
in parts it is thick and spongy ; in the neighborhood of the openings 
of the nares and Eustachian tubes it is thinner, while below it is pale 



MUSCLES OF SOFT PALATE. 



20I 



f 8 




\ V 




Fig. 76. Muscles of Soft Palate Seen from Behind. (Deaver.) 

a, Tensor palati muscle ; b, salpingopharyngeus muscle ; c, levator palati muscle ; 
d, aponeurosis of soft palate ; e, tensor palati tendon ; f, tensor palati muscle ; 
g, Eustachian tube ; h, internal pterygoid muscle ; i, external pterygoid muscle ; 
j, pharyngeal aponeurosis lining constrictors ; /;, lower jaw ; /, palatoglossus 
muscle; m, palatopharyngeus muscle; 11, mvicous membrane; o, azygos uvulae 
muscle ; p, posterior fasciculus of palatopharyngeus muscle ; q, tonsil ; r, palato- 
pharyngeus muscle. 



202 DISEASES OF THE NOSE AND THROAT. 

and arranged in longitudinal folds. It is freely supplied with lymph 
follicles and racemose glands. Its epithelium is ciliated in the rhino- 
pharynx and becomes stratiform in the lower portion (Fig. 76). 

The muscles of the pharynx are the three constrictors, the supe- 
rior, middle and inferior, fortified by fibers of the stylo- and palato- 
pharyngei muscles. The superior constrictor surrounds the upper 
part of the pharynx with the exception of a semi-lunar space on 
either side named the " sinus of Morgagni " which is filled in with 
the pharyngeal aponeurosis and contains the Eustachian tube and 
the levator palati muscle. It is quadrilateral in shape and arises 
from the lower third of the edge of the internal pterygoid plate and 
its hamular process, from the pterygo-maxillary ligament, from the 
posterior fifth of the mylohyoid ridge and the side of the tongue. 
The fibers pass backwards to meet in the median raphe. 

The middle constrictor is fan-shaped and arises from the lesser 
cornua of the hyoid, from the whole length of the greater cornua, 
and from the stylo-hyoid ligament. Its fibers are also inserted into 
the median raphe. The upper ones overlap the superior constrictor 
and reach to the basilar process of the occipital bone, while the lower 
fibers are included within those of the inferior constrictor. 

The inferior constrictor is a thick muscle, very powerful, which 
arises from the thyroid cartilage behind the oblique line and superior 
tubercle as well as from the inferior cornua and from the sides of 
the cricoid behind the crico-thyroid muscle. The upper fibers over- 
lap the middle constrictor while the lower ones are continuous with 
the muscle fibers of the esophagus. Near its upper border the supe- 
rior laryngeal nerve and artery pierce the thyro-hyoid membrane. 
The recurrent laryngeal nerve enters beneath its lower border behind 
the crico-thyroid articulation. 

The stylo-pharyngeus arises from the base of the styloid process 
internally and passes downward and inward between the superior 
and middle constrictors. Its fibers diverge, some joining the palato- 
pharyngeus to be inserted into the posterior border of the thyroid 
cartilage, and the rest mingling with the constrictors. 

The palato-pharyngeus forms the posterior pillar of the fauces. 
It arises from the aponeurosis of the soft palate by two heads sepa- 
rated by the insertion of the levator palati. The upper head blends 



CONSTRICTORS OF PHARYNX. 



203 




1 










Fig. 77. Constrictors of Pharynx. (Deaver.) 

a, Ophthalmic artery ; b, internal carotid artery ; c, sympathetic nerve ; d, in- 
ternal carotid artery ; e, superior cervical ganglion of sympathetic ; f, ascending 
pharyngeal artery ; g, external carotid artery ; h, common carotid artery ; i, lateral 
lobe of thyroid body ; /, inferior thyroid artery ; k, recurrent laryngeal nerve ; 
/, trachea; m, pharyngeal aponeurosis and sinus of Morgagni ; n, buccinator 
muscle ; o, pterygomaxillary ligament ; p, superior constrictor muscle ; q, raphe ; 
r, stylopharyngeus muscle ; s, middle constrictor ; /, greater cornu of hyoid bone ; 
u, inferior constrictor; v, circular muscular fibers of esophagus; w, longitudinal 
muscular fibers of esophagus. 



204 DISEASES OF THE NOSE AXD THROAT. 

with its fellow of the opposite side while the lower, which is the 
thicker, follows the curve of the posterior border of the palate. It 
also has its origin by one or two narrow bundles from the lower 
part of the cartilage of the Eustachian tube known as the salpingo- 
pharyngeus muscle. It is inserted by a narrow band into the pos- 
terior border of the thyroid cartilage near the base of the superior 
cornu and by a broad expansion into the fibrous layer of the pharynx 
at its lower part (Fig. yy). 

The pharynx is separated from the vertebral column by the longus 
colli and rectus capitis antici muscles and by loose areolar tissue. 
Laterally it is in relation with the styloid process and its muscles, 
the glosso-pharyngeal nerve, the lateral lobes of the thyroid gland, 
the sheath of the carotid vessels, the pharyngeal plexus and the 
ascending pharyngeal artery. 

In the vault of the pharynx at its middle portion just below T the 
body of the occipital bone is a pouch called the " pharyngeal bursa." 
It is the persistent lower portion of the pharyngeal diverticulum, the 
" pouch of Rathke," and usually disappears in adult life. 

Distributed over the wall of the rhinopharynx are numerous groups 
of lymphoid follicles comprising the " pharyngeal tonsil." 

The muscles of the pharynx are supplied by the pharyngeal plexus 
and the external and recurrent laryngeal nerves. The stylo-pharyn- 
geus is supplied by the glosso-pharyngeal nerve. 

The pharynx is of unusual interest and importance since it is con- 
cerned in four functions, of respiration, of audition, of phonation, 
and of deglutition. As an example of the importance of a normal 
pharynx to the act of breathing and the function of the ears it is only 
necessary to refer to the morbid condition known as " adenoids " in 
the rhinopharynx, in which " mouth-breathing " and various aural 
disturbances are conspicuous. 

Neoplastic growths, cicatricial contractions and malformations are 
met with in this region w 7 hich may affect one or all of these func- 
tions. Aside from gross lesions it is necessary that the glandular 
apparatus of the pharyngeal mucosa should do its duty properly in 
order to furnish adequate lubrication for the lower pharynx in the 
act of swallowing. A resonant voice of pleasing quality can be 
produced only in the absence of deformity or anomalies in the 
pharyngeal wall. 



ANATOMY AND PHYSIOLOGY OF THE PHARYNX. 205 

The uvula with the velum assists the epiglottis in shutting off the 
buccal cavity in normal nasal respiration, and helps to close the naso- 
pharynx during deglutition. It also directs the nasal secretions 
towards the glosso-epiglottic fosste. When enlarged it frequently 
becomes a source of local or reflex irritation, while a considerable 
part of it may be sacrificed without detriment. On the other hand 
paresis of the palatal muscles, or a cleft of the soft palate has a pro- 
nounced effect both on speech and swallowing. 

The palatal or faucial tonsils are made up of a collection of crypts 
or lacunae, ten to twenty in number, lying between the palatal folds 
and resembling in structure Peyer's patches. Their function has 
been the subject of much speculation. They were once supposed to 
furnish a lubricant for the bolus of food and again to absorb from 
the saliva certain particles as a pabulum for leucocytes. In a nor- 
mal state they are not visible. Whatever their function may be 
they would seem no longer capable of exercising it when hyperplas- 
tic and diseased. It has been shown that leucocytes may migrate 
from the lymphoid tissue into the lacunse between the epithelial cells. 
Recent experiments have demonstrated that grains of carmin placed 
in the crypts appear later in the lymphoid tissue (Goodale). Sim- 
ilar absorption has been observed with various powders placed on 
the surface of the tonsils (Hendelsohn) and in the lower animals 
infection has followed rubbing the tonsillar surface with strepto- 
cocci. The foreign particles were found to have passed not only 
between but through the epithelial cells, the conclusion of Stohr that 
leucocytes pursue only the former course thus being opened to ques- 
tion. These experiments have a most important bearing on the 
conveyance of disease by infection, although they were conducted 
upon hypertrophied and therefore abnormal tonsils, and possibly 
throw no light on the function of normal lymphoid tissue. The 
latest investigations of this subject, with special reference to tuber- 
culosis, show that the tonsils " as portals of infection " are no more 
susceptible than other portions of the mucous surface. In one hun- 
dred cases of pharyngeal tonsil examined by Rethi, six of tubercu- 
losis were found. On the other hand, in more than two hundred 
specimens of lymphoid tissue examined microscopically and bac- 
(criologically by Goruc not one showed a giant cell, a tubercular 



206 DISEASES OF THE NOSE AND THROAT. 

nodule, or a tubercle bacillus. A similar result was obtained by 
Jonathan Wright in a series of 121 cases examined with that obser- 
ver's well-known care and skill. Undoubtedly, however, tubercular 
infection may take place by this route without involving the lym- 
phoid tissue itself, and several interesting- experiences suggest that 
a latent tuberculosis may be excited to activity by operative inter- 
ference with hypertrophied lymphoid tissue in persons previously 
unsuspected (Lermoyez and Chappell). Yet the occurrence of the 
latter is so rare as not to constitute a valid objection to operation in 
these cases, and the study of the subject up to the present time does 
not indicate whether normal is more or less prone than morbid lym- 
phoid tissue to absorb pathogenic germs. On the other hand the 
recent investigations of Pirera, while substantiating the view that the 
palatal tonsils are ready routes of entry for microorganisms, chiefly 
by their lacunar, seem to show that a condition of hyperplasia and 
especially of fibrosis may impede their absorption. In a case recently 
observed by the author suppuration of the cervical glands compli- 
cating a follicular amygdalitis was followed by suppression of urine 
and other signs of renal irritation, attributable, it is believed, to strep- 
tococcic infection. Such occurrences are not very uncommon and 
lend additional importance to simple inflammatory derangements of 
the pharyngeal structures. 



METHODS OF EXAMINATION. 

The method of examining the rhinopharynx has already been 
described. Most of the oropharynx is within reach of the eye, yet 
even here a pharyngoscopic mirror is often useful. The probe is 
essential especially in examining pockets in the tonsillar region, and 
the index finger gives us valuable information as to the consistency 
of certain morbid growths and the mobility of neoplasms. Sharp- 
pointed foreign bodies often become engaged in the follicles at the 
base of the tongue or in the tonsillar crypts, where they may be 
detected by the finger when invisible to the eye. When the pharynx 
is very irritable, or the tongue arches and cannot be depressed by 
moderate force, a fair exposure of the parts may generally be ob- 
tained by directing the patient to take a deep inspiration and then 



EXAMINATION OF THE PHARYNX. 20J 

sing a long " ah." Under ordinary conditions the walls of the 
laryngopharynx are in contact and are open to inspection only 
under the use of a dilating pharyngoscope. It has been proposed 
to examine the upper pharynx with the patient lying flat upon the 
back with the head well extended, the examiner standing at the 
head of the patient and introducing a large laryngeal mirror, the 
shank of which of course rests in the right angle of the patient's 
mouth instead of the left as usual. The awkwardness of the posi- 
tion and the satisfactory view generally obtained with the ordinary 
way of making an examination of the upper pharynx will tend to 
prevent this method from becoming popular. 



CHAPTER XL 

DISEASES OF THE VELUM AND UVULA. BIFID UVULA. NEOPLASMS 
AND MALIGNANT DISEASE OF THE VELUM. CLEFT PALATE. 
UVULITIS AND ELONGATED UVULA. ACUTE AND CHRONIC 
PHARYNGITIS. ATROPHIC PHARYNGITIS. RHEU- 
MATIC PHARYNGITIS. 

BIFID UVULA. 

Bifurcation of the uvula is a very common congenital mal-develop- 
ment. It is an elementary palatal cleft. The two divisions of the 
uvula are often quite symmetrical and placed side by side (Fig. 78). 
In a unique case reported by T. A. DeBlois one uvula was situated 
in front of and almost concealed the other. The furrow rarely in- 
volves the muscular tissue. It seldom has any importance except, 
as sometimes happens, when one of the segments is so displaced as 
to cause cough by tickling the pharyngeal wall. In such cases, unless 




Fig. 78. Bifid Uvula. 

the tissues are extremely redundant, the two halves of the uvula may 
he united by denuding their opposed surfaces and bringing them 
together by means of one or two sutures, or if the tissues are in 
excess one or the other of the subdivisions may be excised. 

Other malformations of the soft palate are sometimes seen, such 
as absence of the uvula or velum, asymmetry of the palatal arches, 

208 



NEOPLASMS OF THE VELUM. 20O, 

and perforation of one of the faucial pillars. In a case of the 
author's perforations large enough to admit an ordinary lead pencil 
and unknown to the patient were discovered in each posterior pillar 
in identical situations. The result of syphilitic ulceration in pro- 
ducing distortion and adhesions will be elsewhere considered. In- 
equality of the sides of the palate may be congenital, independently 
of a paretic condition, while the latter is not infrequently observed 
as a sequel of diphtheria, or as a symptom of cerebral disease. 
Paralysis of the velum in non-diphtheritic nasopharyngitis of high 
intensity has been noted in several cases, among them one of my 
own, in which the loss of power persisted more than a month. 
Spasm of the velum, rhythmic or intermittent, may occur in con- 
nection with a general chorea, producing a distinctly audible sound, 
and more rarely in chronic rhinopharyngitis, causing what is de- 
scribed as " clicking tinnitus." Neoplasms of the palate, with the 
exception of the small warty growths often seen at the margin of 
the velum, are rather rare, although this structure may suffer by 
invasion from other parts. 

No satisfactory cause can be assigned for the development of new 
growths in this region. In several instances a neoplasm supposed 
to be a papilloma has proved malignant. A few cases of fibroma, 
of lipoma, and of angioma of the velum have been reported. A 
case of cyst of the right posterior pillar has been recorded by Jona- 
than Wright. Adenoma is much more frequent and is often com- 
bined with other morbid tissue. It usually occurs in adults and has 
been seen more often in women than in men. Nearly all these 
growths may be safely and readily removed with knife, scissors, or 
snare, although some deeply embedded tumors require considerable 
dissection. With angiomata a cutting operation should be avoided. 
In a case of the latter once under my care the electric cautery worked 
admirably. The simpler forms of these benign neoplasms grow very 
slowly if at all, produce no inconvenience and may properly be left 
alone. 

Malignant disease appears in the form of sarcoma, or of car- 
cinoma, the former, as in other situations, at almost any age, the 
latter usually in adult life. Owing to the scanty lymphatic circula- 
tion in this region glandular involvement is rather tardy. This fact 
'4 



2IO DISEASES OF THE NOSE AND THROAT. 

combined with the relatively non-virulent tendency of sarcoma gives 
reason to hope for good results from early surgical intervention in 
this disease. All kinds of sarcomata are met with. Their growth 
is slow and painless until ulceration develops. The chief symptoms 
relate to the function of the palate. Finally deglutition becomes 
impeded, an ichorous discharge occurs from an ulcerated surface, 
and hemorrhage, even fatal, may take place. It is often difficult to 
differentiate this lesion from epithelioma and it is always necessary 
to exclude syphilis by progressive doses of iodide of potash. 

Epithelioma is more common late in life and in the male sex. Its 
evolution is rapid and highly malignant. Tain is an early and 
prominent symptom. Ulceration with fetid discharge, hemorrhage 
and glandular infiltration follow in order. Cachexia is usually pro- 
nounced. Surgical interference offers little hope and the Coley 
method of injection with the toxins of the bacillus prodigiosus and 
of erysipelas, sometimes effective in sarcoma, is not available. Local 
anesthesia with cocaine, nirvanin, or orthoform, detergent washes 
and general anodynes comprise all the resources at our command. 

( left palate and its appropriate treatment have been fertile topics 
for discussion many years. Space does not permit an exhaustive 
review of the subject, and in fact the condition is more apt to fall 
into the hands of the general surgeon than to the specialist. Suffice 
it to say that all shades of divergent opinion prevail with regard to 
its management, from one holding that mechanical correction of the 
defect is better than surgical intervention to the view that attempts 
at surgical closure should be undertaken in the earliest months of 
life. The technical details of uranoplasty seem to vary with the 
fancy of the operator. No less than twenty operations with slight 
variations bear the name of their respective promoters. Excessive 
tension on the flaps, disturbance of the wound especially by pressure 
from the tongue, and possibly septic infection have been recognized 
as interfering with the reparative process. The first is obviated by 
the formation of mucoperiosteal flaps by curved incisions in the hard 
palate along the alveolus on either side and by incisions carried well 
backward in the soft palate internal to the hanmlar process. An 
attempt to meet the last two difficulties is made in a method of 
operating recently proposed in which a tracheotomy is done and 



CLEFT PALATE. UVULITIS. ELONGATED UVULA. 211 

after the cleft has been closed by sutures the oral cavity and the 
wound generally are firmly packed with sterilized gauze (J. F. Mc- 
Kernon). The trachea tube is retained for ten or twelve days, and 
the dressings are renewed each day, in the meantime feeding being 
carried on by the rectum. An objection to this plan from an aseptic 
standpoint appears in the fact that the salivary secretion is so stimu- 
lated that daily change of the dressings, with more or less distur- 
bance of the wound, is necessary. The added risk of opening the 
trachea is not small and the irritation attendant upon a firm packing 
of the buccal and pharyngeal cavities is hardly compensated for by 
any improvement in results as compared with simpler modes of 
operating. The prognosis as regards defective speech is better the 
younger the patient. In older persons of sensitive organization the 
moral effect of being relieved of a deformity of this kind is very 
considerable, irrespective of other benefits. Defective speech after 
closure of a palatal cleft is due in part to muscular atrophy and in 
part to tension of the velum which the muscles are too weak to over- 
come. With a view to improving these conditions Makuen pro- 
poses first division of adhesions between the pillars and the remnant 
of tonsils, second forcible stretching of the velum with the finger 
after division of tense fibers of the palatal muscles, and finally train- 
ing and development of the palatal muscles by various direct and 
indirect voluntary exercises. Marked improvement has been ob- 
served in cases in which these procedures have been carried out, but 
it does not appear that perfectly normal speech is to be expected 
unless operative interference has been undertaken quite early in the 
formative speech period. 



UVULITIS. ELONGATED UVULA. 

Elongation of the uvula may result from frequent attacks of in- 
flammation involving the velum as well as the pharyngeal structures. 
It causes sensations of tickling or of a foreign body in the pharynx, 
which may lead to a dry persistent cough aggravated while the 
patient is in a recumbent position. Asthmatic attacks and even 
alarming glottic spasm may be induced by a long uvula. Tn a voice 
user the condition may be most important and require immediate 



212 DISEASES OF THE XOSE AND THROAT. 

correction. In moderate cases astringents, such as nitrate of silver, 
or chromic acid, ten or twenty grains to the ounce, will give relief. 
In some cases the general relaxed condition, due to anemia, should 
receive attention by the internal use of ferruginous preparations. 
In post-diphtheritic paralysis associated with a catarrhal condition, 
nerve tonics and electric applications are indicated, but no radical 
local treatment is required. Cases that resist these methods need 
surgical intervention and removal of the tip of the uvula, or uvulot- 
omy must be done. Many instruments have been proposed, so- 
called uvulatomes, for this purpose, but it will be found quite as con- 
venient to seize the tip of the uvula with the nasal forceps and 
remove as much as desired by means of the nasal scissors ; the angle 
which these instruments possess carries the hands of the operator 
out of the line of vision. Anesthesia may be obtained by the previ- 
ous application of a ten per cent, solution of cocaine. The tip of 
the uvula, being drawn somewhat forward, the line of incision is 
more or less oblique and the cut surface is thus made to look back- 
wards so that contact with food in swallowing is to some extent 
avoided. Bleeding is usually very slight and, in most cases, the pain 
of the operation and subsequent discomfort are not of much conse- 
quence. Now and then, however, bleeding is considerable and if 
not checked by astringent applications, requires to be controlled by 
a ligature, or the actual cautery, or as suggested by Carroll Morgan, 
by means of a clip like that attached to a garter. 

With the electro-cautery loop the tip of the uvula may be removed 
bloodlessly, but less quickly than with the uvulatome. The stump 
is perhaps a little more sensitive after a burning than a cutting 
operation. Occasionally after a uvulotomy in neurotic subjects, 
severe neuralgic pain is experienced, but usually with care as to diet 
all reaction subsides in forty-eight hours. It is well not to include 
the muscular tissue of the uvula in the section. Yet almost com- 
plete extirpation of this appendage is now and then witnessed with- 
out apparent detriment to the function of the velum. 

Acute uvulitis is generally an accompaniment of inflammation of 
adjacent structures or a pharyngitis. The uvula sometimes reaches 
the most extraordinary dimensions from edema, and in aggravated 
cases pain and obstruction to swallowing, or breathing, may be ex- 



ACUTE AND CHRONIC PHARYNGITIS. 21 3 

treme. Multiple punctures of the swollen mass with a sharp pointed 
bistoury will permit the serum to drain off and encourage retraction. 
In moderate cases the effect of adrenal extract is said to be mar- 
vellous. Reference is made elsewhere to S. Solis-Cohen's extraordi- 
nary experience with an alarming edema of the velum following an 
application to the fauces of a suprarenal-chloretone solution. Such 
a phenomenon may be explained by a drug-idiosyncrasy on the part 
of the individual or perhaps by some peculiarity in the constitution 
of the medicinal preparation. It may be necessary to excise por- 
tions of the relaxed and edematous tissue in order to give relief. 
Recovery is expedited by spraying the fauces with a solution of 
tannin, or alumnol, ten to twenty grains to the ounce of water. 
Astringent gargles, or lozenges, are sometimes useful. 

Edema of the uvula, often without very acute inflammatory symp- 
toms, may occur in the gouty or rheumatic and in those having some 
renal derangement. In all such cases the condition of the kidneys 
should be especially investigated. 

ACUTE AND CHRONIC PHARYNGITIS. 

The mucous membrane of the pharynx is subject to inflamma- 
tory changes similar to those occurring in the nasal cavities. The 
upper division of the pharynx, known as the rhinopharynx, is part 
of the air track and here we find important pathological processes 
involving the lymphoid tissue as well as neoplastic formations of 
interest. In the middle portion of the pharynx diseased conditions 
are of two-fold importance for the reason that the oropharynx is 
part of the food track as well as of the air track; hence, lesions in 
this situation may affect swallowing as well as breathing. The third 
division of the pharynx, or laryngopharynx, begins at the level of 
the arytenoids and extends to the lower border of the cricoid, is a 
portion of the food track only and rarely falls under the eye of the 
laryngologist except as disease reaches it from the laryngeal cavity. 
Foreign bodies may be detained or neoplasms may develop in this 
region and thence invade the laryngeal cavity, thus involving the 
functions of deglutition, phonation and respiration. 

Inflammation of the pharyngeal mucosa may be acute or chronic. 



2 14 DISEASES OF THE NOSE AND THROAT. 

In the large majority of cases of so-called " cold-in-the-head " the 
prominent subjective symptom is a sensation of dryness referred to 
the region above the level of the soft palate. To the eye the surface 
appears dry, glazed and more or less swollen. This stage of in- 
flammation resembles that occurring in other mucous membranes 
and the course of events is similar to that observed in the nasal 
cavities, but we find the membrane of the pharynx less sensitive and 
more tolerant of strong applications. The soft palate and pillars 
of the fauces may be somewhat swollen and edematous. In the 
course of a few hours serous exudation begins and if the process 
is very intense rupture of capillaries may occur and the secretion is 
stained with blood. Finally it becomes thicker and more viscid, 
and if fibrinous elements predominate, as is apt to be the case in 
severe types of the disease, an exudate, or superficial false membrane 
forms resembling that of diphtheria but not infectious. This con- 
dition is sometimes called "membranous " pharyngitis. If the in- 
flammation extends beyond the limits of the rhinopharynx pain in 
swallowing may be extreme, otherwise in cases of moderate severity 
there may be nothing more than a feeling of fulness or uneasiness 
in the throat. There is constant desire to clear the throat and to 
swallow. The degree to which the voice and the senses of smell 
and hearing are affected depends wholly upon the intensity and 
extent of the pharyngeal inflammation. There is usually some fever 
and general disturbance and the patient may really feel quite id. 
The prognosis, in the absence of complications in the form of some 
organic or constitutional disease, is good, the parts resuming their 
previous condition in the course of a week or ten days. In many 
cases, however, a chronic catarrhal condition results. 

The patient seldom attaches enough importance to his trouble to 
seek advice, so that we rarely see these cases early enough to do any 
good with ice applications externally. About all that can be done 
is to soothe the irritated parts by bland alkaline sprays followed by 
a protective coating of mentholized albolene, two to five grains of 
menthol to the ounce. Benzoinated steam inhalations are some- 
times grateful. Attention should be given to a gouty or rheumatic 
diathesis, as well as to possible derangements of the gastrointestinal 
track, and a brisk purgative is often indicated. If the sufferings of 



CHRONIC PHARYNGITIS. 21 5 

the patient are considerable codeine or some of the coal-tar products, 
as phenacetin with salol, may be used cautiously. Belladonna, in 
the familiar rhinitis tablet, is sometimes useful. The local use of 
astringents is not to be recommended as they merely aggravate the 
discomfort. 

A very large proportion of chronic inflammatory conditions met 
with in this region are secondary to some lesion or deformity of the 
nasal chambers which will require correction before anything can 
be accomplished in the way of relieving the pharyngeal conditions. 
A simple catarrhal pharyngitis will sometimes yield to mild sedative 
or astringent applications which have been referred to in speaking 
of the therapeutics of rhinitis ; in cases which prove more rebellious 
it will be necessary to look for some etiological factor within the 
nose or in the accessory sinuses. In not a few cases too of chronic 
pharyngitis the cause must be sought in the digestive track. Dys- 
peptics almost invariably present more or less of an index of their 
condition in the mucous membrane of the pharynx. Occasionally 
we meet with an inflammatory condition involving chiefly the fol- 
licular elements of the pharyngeal mucous membrane constituting 
what is known as granular or follicular pharyngitis, or clergyman's 
sore throat, in which enlarged papilla?, or lymphoid nodules hyper- 
plastic in character, are distributed at intervals over the surface of 
the membrane. The temptation to remove these protuberances by 
means of the curette or destructive caustics should be resisted since, 
in many cases, the condition is symptomatic and radical measures 
directed to the local lesion will be in danger of encouraging a ten- 
dency to atrophy of the mucous membrane and may leave the patient 
more uncomfortable than he was originally. In some aggravated 
cases it may be justifiable to touch the follicles with a chemical 
caustic, preferably trichloracetic acid, or the point of an electric 
cautery, care being taken to avoid making the application too exten- 
sive. On inspection of the fauces of certain individuals suffering 
from chronic pharyngitis there may be seen in the middle of the 
pharyngeal wall an area of dry, glazed mucous membrane, dotted 
here and there with enlarged follicles and perhaps coated with a 
layer of tenacious secretion, and bounded on either side by a vertical 
band of red, thickened mucous membrane (Fig. 79). These lateral 



2l6 DISEASES OF THE NOSE AND THROAT. 

bands extend to the posterior pillars, which are themselves often 
much thickened, and they have been considered important enough to 
receive the independent title " pharyngitis hypertrophica lateralis." 
As a matter of fact they should always be looked upon as indicative 
of disease in the vault of the pharynx or in the nasal chambers. 
According to the histological researches of Cordes the bands 
consist of collections of lymphoid follicles embedded in a fibrous 




I 1 



Fig. 79. Chronic Follicular Pharyngitis and Hypertrophy of Lateral 
Bands. ( Grunwald. ) 

reticulum and arc analogous in structure to the palatal tonsils and 
to adenoids in the pharyngeal vault. It is clear that the remedy for 
them is to be found in giving first attention to the morbid condition 
higher up in the air track which acts as the exciting cause. The 
accumulation of secretion in the nasopharynx in chronic pharyngitis 
is sometimes a source of annoyance which may be relieved bv irri- 



CHRONIC PHARYNGITIS. 21 J 

gation of the parts by means of the postnasal syringe with warm 
alkaline solutions. Equal results may be obtained in some cases of 
irritable pharynx with more comfort to the patient by means of a 
spray forced through one anterior naris and allowed to escape by 
the opposite nostril. In the early stages, if the secretion is profuse, 
a mentholized albolene spray through the anterior nares will be 
found to give relief. Not infrequently annoying aural complications 
result from blocking up of the Eustachian tube. When the aural 
symptoms are purely congestive, they may be relieved to some de- 
gree by mentholated spray or applications of suprarenal extract to 
the vault of the pharynx. 

Inflammatory conditions in the nasopharynx are not infrequent 
complications or sequelae of the exanthemata and in the latter case 
may be benefited by general tonic treatment in combination with local 
applications. 

A chronic nasopharyngitis is perhaps the most annoying and fre- 
quent of the morbid conditions with which we meet. The victims 
of it are generally burdens to themselves and sources of disgust to 
their neighbors from the constant hawking and clearing efforts 
demanded by the tenacious secretions accumulated in the vault. 
There is no doubt that many patients get into the habit of rasping 
their throats in this way quite unnecessarily. They should there- 
fore be urged to resist the desire as far as possible. In the treat- 
ment of this condition our main reliance is on the selection of a 
suitable astringent so applied after careful cleansing as to reach the 
whole surface. In some cases, a postnasal application must be 
supplemented by one made through the anterior nares. Sulphocar- 
bolate of zinc, ten grains to the ounce, alumnol, ten to twenty grains 
to the ounce, have, in my experience, proven the most agreeable and 
effective astringents. Nitrate of silver, twenty to thirty grains to 
the ounce, glycerol of tannin, or tincture of iodin, in cases of long 
standing in which the tissues are hyperplastic, may be more service- 
able. These agents are best applied with a probe, the tip of which 
is bent at a right angle and wound with cotton. Once or twice a 
week is often enough for the stronger applications, the daily use of 
the milder solutions being continued in the intervals. The treat- 
ment should always be preceded by thorough cleansing of the parts 



2l8 DISEASES OF THE NOSE AND THROAT. 

with alkaline irrigations by means of the anterior douche or the 
postnasal syringe. For the more aggravated cases even more pow- 
erful applications may be indicated. Bosworth recommends undi- 
luted monochloracetic acid and suggests lactic acid thirty to sixty 
grains to the ounce, or a guarded porte-caustique of his own device 
intended for fused chromic acid or nitrate of silver may be used. 
These energetic measures are neither agreeable to the patient nor 
Aery efficacious, the authority just quoted admitting that results are 
unsatisfactory even from prolonged treatment. Internal medication 
may have no specific effect but is often important in conditions of 
anemia, of gastrointestinal derangement, or in the gouty or rheu- 
matic diathesis. Beverly Robinson speaks highly of cubebs inter- 
nally with a view to rendering the mucous secretion more fluid and 
hence more easily disposed of. Alcohol except in very moderate 
quantities should be interdicted, and the use of tobacco, especially 
when the habit of inhaling the smoke is practiced, should be re- 
stricted. The mode of life in general as to bathing, dress, exercise 
and diet must be supervised, but above all it is essential to remove 
an intranasal abnormality or obstruction which may interfere with 
normal ventilation and drainage of the nasal track. While excessive 
vigor in intranasal surgery is to be deprecated, it is surprising to 
what extent distressing subjective symptoms may be relieved by 
removal of an apparently unimportant nasal lesion. Such anomalies 
develop so gradually that the patient becomes accustomed to them 
and fails to appreciate their magnitude, whereas an equal degree of 
obstruction suddenly imposed would be intolerable. After all has 
been done a certain proportion, unfortunately a large one, of these 
cases continue to be annoyed by their " dropping " in the throat and 
by their morning clearing out process, and after going from one 
specialist to another and one climate to another with possible tem- 
porary improvement settle down to the conviction that they are in- 
curable. Ultimately nature takes charge of the case and with ad- 
vancing years more or less mitigation of symptoms is experienced. 



ATROPHIC PHARYNGITIS. 2 I 9 



ATROPHIC PHARYNGITIS. 

Pharyngitis sicca, or atrophic pharyngitis, is the result of an in- 
flammatory process induced by some local irritation, or probably con- 
secutive to a similar state in the nasal chambers. It may be asso- 
ciated with a constitutional condition characterized by malnutrition. 
The glandular secretion is perverted in quality and tends to adhere 
to the surface of the pharynx in dry scales or crusts, or as a thin 
film of inspissated mucus. On the other hand sometimes the sur- 
face looks dry, thin and glazed, and has the appearance of having 
been varnished. The perverted secretion is itself a source of irrita- 
tion and leads to connective tissue cell proliferation and eventually 
a contracting process takes place which obliterates the blood supply 
and destroys the secreting glands. A great variety of bacteria are 
found in the secretions but there is no evidence to prove that they 
are, in any degree, an etiological factor. A subjective sensation of 
dryness, accompanied by burning or itching and a desire to swallow, 
are the most prominent symptoms. There may be some difficulty in 
swallowing owing to deficient lubrication or to rigidity of the mus- 
cles. In most cases the dry secretions are very tough and adherent. 
The patient is annoyed by a constant desire to relieve himself by 
hawking and even thus does not succeed in dislodging the mucus. 
When the secretions have been cleared off the membrane is obviously 
thinner than normal and is very apt to be somewhat mottled, in cer- 
tain regions being congested, in others, pale. An unpleasant odor is 
imparted to the breath by the decomposing secretions. 

The prognosis, as in atrophic rhinitis, depends upon the stage of 
advancement of the process. 

No treatment will restore glands that have been destroyed. But, 
if the disease is attributable to certain local irritants which can be 
removed and if the atrophy has not progressed too far, the results 
of treatment are more encouraging. Any associated nasal deformity 
or disease must be removed. The first essential, as in cases of nasal 
disorders, is perfect cleanliness, which must be secured at the outset 
by careful and thorough spraying or swabbing of the region with 
an alkaline wash followed by a mild degree of local stimulation ; the 



2 20 DISEASES OF THE NOSE AND THROAT. 

latter may be attained by the application of strong solutions of ieh- 
thyol or formalin. These stimulating applications should be used 
with caution and their strength must be determined for each indi- 
vidual case. At the conclusion of treatment the parts should be 
protected by spraying with a solution of menthol in albolene, about 
five grains to the ounce. By patient perseverance in this course 
much may be accomplished even in apparently bad cases, at least 
as regards the relief of distressing symptoms. Electricity in the 
form of faradism has been found of benefit, the positive pole being 
in contact with the pharyngeal wall while the negative is held in 
the hand of the patient (Seiss). The current may be applied for 
two or three minutes with advantage. Galvanism, used as in the 
case of nasal atrophy, is beneficial. Massage, by means of a me- 
chanical vibrator, or by hand with a probe wound with cotton, is of 
service. If desired the cotton may be moistened with thymol, iodin, 
or carbolic acid in oily solution. Sometimes one agent and again 
another seems to act more satisfactorily. 

Internally we might expect good results from drugs known to 
influence glandular secretion, such as jaborandi, pilocarpin, or the 
iodid salts. Occasionally they appear to give temporary relief by 
supplying moisture to the dry surfaces, but they cannot be long 
continued without danger of disturbing the stomach. Careful at- 
tention should be paid to the digestive function and if necessary 
constipation should be corrected by the use of saline or other laxa- 
tives. Good hygiene and the general regime and treatment referred 
to in speaking of rhinitis are equally important in inflammation of 
the pharynx. 

RHEUMATIC PHARYNGITIS. 

The effects of the rheumatic diathesis upon the fibrous tissues of 
the pharyngeal wall are generally admitted but no definite local symp- 
toms can be considered characteristic. Cases vary in their subjective 
phenomena and we have to rely on the general symptoms and on 
the rheumatic history in making a diagnosis. The general rheu- 
matic disturbance, such as inflammation of muscles and joints, may 
nnt appear until after the pharyngeal symptoms have become estab- 
lished, or the latter may be secondary and insignificant. In most 



RHEUMATIC PHARYNGITIS. 221 

cases the local appearances are less intense than in ordinary acute 
pharyngitis and are abrupt in onset and disappearance. The pain in 
swallowing is out of proportion to the inflammatory appearances and 
is not influenced by the usual local remedies employed in simple ton- 
sillitis or pharyngitis. It is usually met with at or after middle life 
and not infrequently follows exposure. Fatigue and depressed gen- 
eral health predispose to an attack. Relapses are frequent and it 
is noticed that outbreaks of the affection are common in the spring 
and fall of the year or after a decided fall of temperature. 

Local treatment is of little avail, although the application of heat 
is sometimes grateful. Cases usually respond as soon as the system 
is under the influence of anti-rheumatic medication. The salicylates, 
especially the salicylate of sodium in ten-grain doses every four 
hours, give the most satisfaction. Some cases seem to act better 
under the alkaline treatment, small doses of bicarbonate of soda, of 
sodium phosphate, or of Rochelle or Carlsbad salts being adminis- 
tered at short intervals. 

While it seems to be established that a very large proportion, 
according to St. Clair Thomson from thirty to thirty-eight per cent., 
of cases of acute rheumatism begin with an angina, yet the local 
pharyngeal indications are indefinite. Apparently the parenchyma- 
tous or follicular form of amygdalitis, rather than the phlegmonous, 
or quinsy, is the rheumatic type. At any rate antirheumatic reme- 
dies are often effective in the former and are much less so in the 
latter. Possibly the rheumatic virus may enter the system by way 
of the pharynx, as is the case with other poisons, and leave no local 
indications. 



CHAPTER XII. 



ADENOIDS IN THE RHINOPHARYNX. 



The name tonsil has been applied to various collections of lym- 
phoid tissue beside those between the palatal folds ; at the base of 
the tongue is the lingual tonsil ; in the vault of the pharynx the 
pharyngeal tonsil ; in addition, small masses in or near the ventricles 
of the larynx are called the laryngeal tonsils ; and of still less im- 
portance the aggregations within the nostrils are known as the nasal 
tonsils. 

The collection in the vault of the pharynx, the pharyngeal tonsil, 
or adenoids, is perhaps the most important. It is a conglomerate 
gland, covered by thin mucous membrane and columnar epithelium, 
sometimes ciliated. It is a vascular body and, like the faucial ton- 
sil, is a normal organ which is disposed to undergo atrophy at about 
maturity. The idea that tonsils are normal bodies is vigorously com- 
bated by Bosworth, who contends that a visible tonsil is an abnor- 
mality and should be removed like any other tumor. Xo one at the 
present day is likely to affirm that an organ is " normal " which is 
itself diseased or may be the cause of morbid conditions elsewhere, 
yet it is often equally difficult to define the boundary between a nor- 
mal and an abnormal tonsil and to decide whether in a given case 
a mass of lymphoid tissue needs to be removed. Many diseased ton- 
sils are carried through life without detriment and the latter question 
hinges mainly on the degree of subjective disturbance they excite 
rather than on their dimensions or degree of abnormality. Nodules 
of lymphoid tissue are undoubtedly normal in certain regions. Per- 
haps we may admit the correctness of the view that " the tonsils 
are pathological entities when they can be demonstrated clinically," 
but that is very different from saying that all tonsils should be 
removed. The points to be determined are, first, whether the en- 
larged lymph nodes have ceased to perform their function, presum- 
ably that of defending the system against infectious germs, and, 



ADENOIDS. 223 

second, whether they are a cause of local or general derangement. 
The pharyngeal tonsil has been particularly described by the 
German anatomist Luschka and is sometimes called " Luschka's 
bursa or tonsil," this name being restricted to the main aggregation 
of lymphoid tissue in the middle of the pharyngeal vault. A large 
crypt or lacuna in the midst of this bursa often ends in a dilated 
extremity which sometimes becomes distended by accumulation of 
secretion owing to obstruction of its outlet, thus forming a cyst of 




Fig. 80. Adenoids in Rhinopharynx. (Grilnwald.) 



considerable dimensions which occasionally undergoes suppuration. 
It has been particularly studied by Tornwaldt and from him is known 
as Tornwaldt's disease, or cyst of the pharyngeal bursa. The 
pharyngeal tonsil, or adenoid vegetations, becomes of interest and 
importance in its enlarged condition from the obstruction it offers 
to nasal respiration, from disturbance it may excite in the ear by 
pressure in the region of the Eustachian tube or orifice, and from 



2 24 DISEASES OF THE NOSE AND THROAT. 

the causative relation it bears to various other disorders, reflex de- 
rangements as well as infectious diseases (Fig. 80). 

Adenoids may be met with very early in life, if they are not 
actually congenital. They are always an impediment to health and 
in a nursing infant may be a serious obstacle to nutrition. They are 
seldom seen in adults, although several marked examples in very 
old subjects have been recorded. Remnants of lymphoid tissue and 
the evidences of the damage it has done are frequently recognized 
in elderly people. 

The cause of this morbid condition is not always discoverable, but 
it is evidently a frequent sequel of the exanthemata in children and, 
in a large proportion of cases, is associated with a general dyscrasia 
resembling struma which has been described by Potain under the 
name lymphatism. 

The subject of the condition, when it exists in a marked degree, 
presents a facial expression which is in a measure pathognomonic. 
If a child he goes about with open mouth and a very dull counte- 
nance, the eyes are heavy and stupid, the external nose is rather 
small and undeveloped and the upper lip is thick and prominent. 
Effacement of the naso-labial furrow and distention of the trans- 
verse nasal vein are often noticeable. The palatal arch is usually 
high, narrow and V-shaped, and the upper jaw tends to protrude. 
Nasal breathing, through the day, may be natural or impeded, but 
at night respiration is noisy and labored. The child frequently 
awakens from sleep suddenly as though startled by troubled dreams. 
The voice has a peculiar quality called the " dead voice " in which 
there is decided lack of resonance. Hearing is generally impaired 
and the patient has frequent attacks of earache. Nose-bleed is a 
common symptom and, in children, should always excite suspicion 
of the existence of adenoids. A purulent discharge from the nostrils, 
often producing excoriation and eczema of the upper lip, is a very 
common occurrence, especially in the lower classes as a result of 
uncleanliness. Frequently the patient is disturbed by hacking cough, 
paroxysmal in character, or actual attacks of laryngismus may be 
induced by this pathological condition. Asthma, chorea, enuresis 
and prolapse of the rectum are some of the ills attributed with more 
or less reason to adenoids. Deformity of the chest wall, " pigeon 



ADENOIDS. 22 5 

breast," is referred by some to labored respiration caused by the 
clogging up of the postnasal space. Probably the thoracic defor- 
mity is due quite as much to the depraved systemic condition as to 
the mechanical obstruction to breathing. We find many cases oc- 
curring in the same family, whether attributable to heredity or to the 
fact that the patients are all in a similar environment is not deter- 
mined. It would seem as though climatic and atmospheric condi- 
tions play an important part in the development of the lesion. 
Dampness, bad air and unsanitary surroundings certainly predis- 
pose to it. Enlargement is not always due to hyperplasia or in- 
creased connective tissue but may be a simple temporary turges- 
cence; consequently it is not unusual to see extreme changes in the 
dimensions of the adenoid mass. When it has been subjected to 
repeated attacks of acute or subacute inflammation more or less per- 
manent thickening results. Lennox Browne suggests a relationship 
between adenoid vegetations and laryngeal neoplasms in children 
from the fact that the former are " responsible for much infantile 
laryngitis," a condition doubtless predisposing to neoplastic forma- 
tion. He refers to cases of dyspnea after removal of a tracheal 
canula in diphtheria relieved by ablation of adenoids (Martha) in 
confirmation of his opinion that excision of tonsils and adenoids is 
advisable even in an acute stage of diphtheria as a means of avert- 
ing the necessity of a tracheotomy. The propriety of eliminating 
morbid conditions in the upper air track in new growths of the larynx 
cannot be questioned, yet the proportion of the latter to hyper- 
trophied tonsils and adenoids is so small that an etiological connec- 
tion is very doubtful. In the light of the present improved thera- 
peutics of diphtheria the radical disposal of enlarged tonsils in the 
course of that disease as proposed will hardly meet with general 
favor. 

From a pathological standpoint four varieties of adenoid growths 
have been described (Kyle). First, a soft, diffuse, friable mass, 
composed mostly of lymphoid tissue and covered with a thin layer 
of epithelium. Second, an edematous, or cyanotic, form in which 
the gland tissue is but slightly increased, the enlargement resulting 
rather from venous stasis and edema. It is apt to occur in children 
affected bv some intestinal irritation or circulatory disturbance. 



226 DISEASES OF THE NOSE AND THROAT. 

Third, a hard variety in which there is decided increase of connec- 
tive tissue as well as of lymphatic elements. Fourth, also a hard 
form caused by repeated attacks of acute or subacute inflammation 
followed by organization of connective tissue and moderate contrac- 
tion. It is usually secondary to intranasal disease. 

For practical purposes a division into soft and hard meets all 
requirements. Tt is quite prohahle that many adenoid cases are 
needlessly subjected to operative interference, owing to lack of 
appreciation of the fact that in some children these lymphoid struc- 
tures are very sensitive to external impressions and systemic derange- 
ments. They are prone to temporary turgescence or inflammation, 
when many of the subjective symptoms caused by established lym- 
phoid hyperplasia or by an acute inflammatory process may be ex- 
hibited. Preparations may be made to operate on a case of this 
kind and when the time comes little or nothing may be found to 
be attacked. 

The symptoms of adenoids vary with the degree of their develop- 
ment and the relative dimensions of the nasopharynx. A moderate 
mass in a contracted pharynx may create grave disturbance, while 
a large volume may be carried in a capacious pharynx without much 
complaint. The temperament of the patient also has a bearing on 
the subjective symptoms. In a nervous impressionable child the 
general perturbation is more marked than in one of phlegmatic dis- 
position. As already suggested the symptoms refer primarily to 
the functions of respiration and audition. A very large proportion 
of cases of impaired hearing in adults may be traced to neglected 
adenoids in childhood. A very curious condition of mental lethargy 
denominated a proserin (Guye), marked chiefly by inability to con- 
centrate the attention, is clearly referable to this condition. Chil- 
dren previously stupid and backward frequently gain average intel- 
ligence after having been relieved of their impediments. The dul- 
ness in these children is explained in part by impairment of hearing 
and in part by the obstruction to the cerebral lymphatic circulation. 
An interesting example of this condition reported by Jonathan 
Wright occurred in a boy of fifteen who complained that "he could 
not remember or fix his mind on his tasks." Two or three minutes 
after a digital examination, which revealed a considerable collection 



ADENOIDS. 227 

of adenoids, he fell in a slight convulsion lasting less than a minute. 
On recovery he appeared dazed and stupid for some moments and 
was impressed by the belief that he had been given an electric shock. 
This and a similar case are looked upon as instances of nasopharyn- 
geal reflex as well as of aprosexia, the former assumption being less 
well founded than the latter. Care should be taken not to confound 
the shock and faintness attendant upon an examination like that 
made in these cases, and especially apt to occur in children of the 
adenoid class displaying the neurotic disposition, with a true reflex. 
There is an unmistakable impression upon the general health as a 
result of the restlessness at night caused by mouth breathing. The 
obstacle to respiration is aggravated by the increase of blood in the 
parts in a recumbent position and by the muscular relaxation occur- 
ring in sleep. In most cases the faucial tonsils are also hypertro- 
phied and drag the tongue back over the larynx in such a way as to 
still further constrict the air channel. A peculiar change in the 
quality of the voice is almost invariable, but frequently in addition 
there is a faulty enunciation of some of the consonants, or actual 
stuttering results. Frequently the glands at the angle of the jaw 
or in the lower cervical triangle are enlarged. The sense of taste 
may be impaired or lost from dry mouth. The act of swallowing 
may be interfered with, and not infrequently food is regurgitated 
into the nasopharynx from relaxation of the soft palate. 

The diagnosis is seldom difficult ; usually the facial expression is 
characteristic and the condition may be surmised at a glance. At- 
tention has recently been directed by Champeaux to the fact that 
the so-called " adenoid facies " may be simulated in certain condi- 
tions of nasal obstruction and may be quite pronounced when no 
adenoids whatever are present, and on the contrary some cases of 
extreme lymphoid hyperplasia do not exhibit the typical physiog- 
nomy. The following are enumerated by Chappell among the con- 
ditions causing respiratory stenosis resembling that due to adenoids. 
Most of them are peculiar to early life and several are so rare as to 
be unworthy of consideration. (1) Lymphatism and lithemia, (2) 
syphilitic and gonorrheal rhinitis, (3) congenital occlusion of the 
nares, (4) digestive disturbances, (5) congenitally high arched pal- 
ate, (6) small or occluded nostril, (7) unusually small postnasal 



228 DISEASES OF THE XOSE AND THROAT. 

space, (8) anterior projection of the bodies of the cervical verte- 
brae, (9) some malformations of the soft palate, (10) hypertrophy 
of the tongue. Natier also insists that in certain neurotic children 
a state of " false adenoidism " sometimes exists which may be cor- 
rected by attention to the general health and by the use of method- 
ical breathing exercises, and in which operative treatment should 
be avoided. It would appear, therefore, that a positive opinion can- 
not be safely based upon suspicious appearances. The rhinoscope, 
or the finger, must be used in every case. In young children pharyn- 
goscopic examination may not be feasible, yet with a little patience 
a satisfactory view may be obtained even in unpromising subjects. 
Digital examination gives us infallible testimony. It is not very 
agreeable to the patient but may be done with celerity and safety in 





Fig. 81. Adenoids in Vault of Pharynx Seen Through Dilated Anterior 
Nares. (Griinwald.) 

a way elsewhere described (p. 35). The sensation conveyed to the 
finger by a mass of adenoids is unmistakable. It has been likened to 
that of a bunch of " earth worms." The soft form of adenoids is 
elastic, compressible, lobulated and vascular, so that the examining 
finger on its withdrawal is stained with blood even though but 
little force has been used. The hard variety is more resistant and 
smoother as well as less vascular. If a rhinoscopic view is possible 
the arches of the choanae are seen to be obscured by pendulous 
masses hanging from the vault and often invading the posterior 
nares. The view obtained in the mirror is very deceptive and should 
not be relied upon in estimating the quantity of adenoid vegetations 



ADENOIDS. 229 

in a given case. An opinion as to treatment must be based upon the 
history of the case and the information gained by exploring with 
the finger (Fig. 81). 

The prognosis is good provided the condition be recognized early 
and the adenoids thoroughly removed. If allowed to remain with 
the hope of the occurrence of atrophy, associated derangements, as 
for example in the ears, may progress to an irremediable degree. 
In the hard variety of adenoids there is no use in wasting time over 
local applications or in an endeavor to improve the general condi- 
tion of the patient. The depraved general state is so clearly aggra- 
vated by, if not the direct result of, the local condition that the lat- 
ter demands first attention. Engorgement of the adenoid mass due 
to inflammatory or intestinal disturbance may be relieved by appro- 
priate treatment and does not require the radical interference de- 




Fig. 82. Denhard's Mouth-gag. 

manded in established disease. In the soft variety and in very 
young children when the symptoms have not long existed removal 
of the mass by simply scraping with the index finger will frequently 
suffice. In infants of two years and under this may be readily done 
without an anesthetic, attention being paid as far as possible to 
asepticism by preliminary cleansing of the hands of the operator and 
of the nasopharynx with a saturated boric acid solution. In these 
cases and when an anesthetic is used the jaws must be held apart 
with a mouth gag (Fig. 82). 

In older children in whom obstructive symptoms are persistent 
it is a better plan to remove the growths thoroughly under ether or 
other anesthetic. Thus the shock of the operation is less. and oppor- 
tunity is given for deliberate and careful exploration and, conse- 
quently, more thorough removal. 



230 DISEASES OF THE NOSE AND THROAT. 

Contrary to the generally received opinion that chloroform is a 
safe anesthetic in children T. H. Halsted maintains with much rea- 
son that the lymphatic diathesis especially favors the depressing 
effect of chloroform upon the heart. This observer prefers ether, 
and to mitigate its suffocative effects and the after nausea he recom- 
mends the instillation into the nares of two or three drops of a five 
or ten per cent, solution of cocaine. Nevertheless many operators 
rely upon chloroform at all ages, in spite of the fact that it is less 
safe than ether. The indiscriminate use of cocaine is unwise, yet 
it seems to be clearly established that reflex respiratory inhibition 
may be prevented by an application of a two per cent, solution of 
cocaine. According to George Crile a much weaker solution, even 
a 0.5 per cent., is effectual. It is well known that atropine prevents 
cardiac inhibition. This observer goes so far as to advise in opera- 
tions in this region a preliminary application of cocaine or eucaine 
and a hypodermic of atropine. With the mode of anesthetization 
presently to be recommended the employment of these drugs is en- 
tirely unnecessary. The statement is made by James Ewing that 
about fifteen deaths from chloroform in lymphoid cases have come 
to his knowledge and the conviction is growing that chloroform is 
especially fatal in cases of this class. In the face of all the adverse 
testimony its continued use should not be countenanced. 

The number of casualties under general anesthesia has reached so 
large a total, very many cases never having been reported, that we 
are called upon to exercise the utmost care and intelligence in the 
administration of whatever anesthetic may be selected. So far as 
possible all contraindications should be eliminated and the actual 
responsibility of giving it should be entrusted only to an expert. 
The observation and experience of F. W. Hinkel fully corroborate 
the views just expressed and justify the conviction that chloroform 
should never be used in these cases. Its advantages by no means 
outweigh its perils and should not be considered in the presence of 
other anesthetics relatively safe and equally effective. 

Ethyl bromide and ethyl chloride are used more or less, but their 
dangers have been repeatedly pointed out, especially as suggested 
by Zematsky in atheroma and alcoholism, conditions which seldom 
prevail in adenoid cases. Great care should be employed in the 



ANESTHESIA IN ADENECTOMY. 23 I 

manufacture of ethyl bromide. It is possible that some of the acci- 
dents attending its administration and consequent prejudice against 
it may be due to the use of an impure product. Eman and De 
Roaldes, whose experience with it has been extensive and favorable, 
lay stress on this particular. It should be given to a patient only in 
the recumbent position, and unconsciousness may be induced rapidly 
by giving five to ten grammes of ethyl bromide before chloroform 
or ether. Schmidt mentions the occurrence of death in five cases 
under ethyl bromide presumably due to cardiac weakness. On the 
other hand Gleitsmann, who formerly preferred the well-known 
A.C.E. mixture, has used ethyl bromide in many hundred cases with- 
out an accident. Emil Mayer has had excellent satisfaction with the 
Schleich mixture, of which about four drachms is sufficient to pro- 
duce complete narcosis in four to six minutes, and recovery is equally 
rapid, but his confidence in this combination is not generally shared 
because of the notoriously unequal volatility of its ingredients. 

It is improbable that general agreement will ever be reached as to 
the kind of anesthetic desirable, or even as to the necessity of any 
anesthetic. It is the custom with many general practitioners to 




Fig. 83. Schuetz's Adenotome. 

scrape the vault of the pharynx of very young children with the 
finger nail, but the nail is far from being an aseptic or an effective 
instrument in most cases. This method without anesthesia may 
answer in clinics, but will not do in private practice, if we wish to 
retain the trust and good will of our little patients. A vigorous 
opponent of anesthesia appears in H. Gradle, who thinks to have 
solved the problem by a special adenotome, modified from one pro- 
posed by Schuetz ( Fig. 83). The size and curve of the instrument 
are such as to fit any pharynx above the fourth year, and in nil her 



232 DISEASES OF THE NOSE AND THROAT. 

a large experience he has found it invariably capable of removing 
all the growth with much less hemorrhage than after any other mode 
of operating. Its quick action is relatively painless, and there is 
less shock and less risk than with any instrument under general anes- 
thesia. The latter this observer condemns, except in unmanage- 
able children, or when the faucial tonsils are to be removed at the 
same time. 

The method of giving ether elaborated by Fillebrown and Rogers 
is sometimes recommended, but is more especially useful in long 
operations in which it is important that the manipulations of the 
surgeon should not be interfered with. In their apparatus ether 
vapor is forced through a tube to the patient's face by means of a 
bellows worked by the foot. 

My own preference is strongly in favor of the use of nitrous oxide 
gas, followed by ether, as being decidedly the safest and most ex- 
peditious mode of procedure. The danger of anesthesia is thus 
reduced to the lowest possible degree and the operation itself is 
much expedited by preliminary use of nitrous oxide. 

All danger of asphyxiation from inspiration of foreign matter 
is obviated by placing the patient in Rose's position with the head 
dependent over the end of the operating table so that blood clots 
and debris accumulate in the pharynx rather than gravitate towards 
the larynx. The upright position in operating was preferred by the 
late F. H. Hooper, who was among the first in this country to realize 
the serious importance of adenoid hypertrophy. His contributions 
to the literature of the subject and his suggestions as to operative 
technique possess a permanent value. His views as to position in 
this as well as in other operations in the upper air track have some 
advocates at the present day, among them T. R. French, who has 
devised a chair to which the patient is strapped after partial anes- 
thesia in a horizontal position. In order to avoid disturbance of 
circulation and cerebral anemia the patient must be very slowly 
raised to a sitting posture. The advantages claimed are first, 
marked reduction in amount of blood lost, second, lessened chance 
of ear complications owing to thorough drainage of blood from 
the rhinopharynx, third, retention of the usual relationship between 
operator and patient, whereby the operation is much facilitated. In 



ADENECTOMY. 



233 



certain cases loss of blood may be a matter of some consequence, but 
as a rule hemorrhage in adenectomy is inconsiderable. In some 
other operations, as that for deviated septum, it is more important. 
Great stress is laid upon danger to the ears from retention of blood 
clots about the Eustachian orifices, which seems to me more fancied 




Meyer's Ring Knife. 



than real in the light of my experience with the recumbent position 
without a single case of ear complication. There is some force in 
the statement that operations with the head dependent are more 
awkward and difficult than when it is upright in a position to which 
we are accustomed in everyday work. This would be more gener- 




Fig. 85. Loewenberg' 



ally admissible, but for the fact that the operation for adenoids is 
usually done without the aid of the sense of sight. 

In the early periods operative procedures, as practiced and recom- 
mended by Meyer, of Copenhagen, whose name has been made illus- 
trious by his invaluable researches on this subject, consisted of 




Fig. 86. Brandegee's Adenoid Forceps. 



removal of these growths by the sharp curette, or ring knife, passed 
through the anterior naris and guided by the finger introduced behind 
the velum (Fig. 84). It soon became apparent that they could be 
more easily reached through the mouth and various post-nasal for- 



234 DISEASES OF THE NOSE AND THROAT. 

ceps have been devised for the purpose. Those first used were in- 
tended for avulsion (Fig. 85) but in attempting to tear the growth 
from its site there is danger of stripping up the mucous membrane 
so that cutting instruments are now preferred (Fig. 86). The 
blades of the forceps in use to-day are much larger than those orig- 
inally employed with the object of enabling us to do the operation 




Fig. 87. Schuetz' Anteroposterior Forceps. 

more rapidly. It is a good plan to have a variety of forceps and cur- 
ettes, some to cut antero-posteriorly and some laterally (Fig. 87). 
The forefinger or steel finger nail as recommended by Dalby or 
Motais (Fig. 88), with the Gottstein curette (Fig. 89) and the 
large-bladed forceps of the author (Fig. 90) comprise the instru- 
ments capable of meeting all possible contingencies. Many operators 



Fig. 88. Motais' Artificial Finger Nail. 

express strong preference for the cold wire snare to be introduced 
through the nostril or by means of a curved canula behind the velum. 
In rare cases in which the patient refuses to submit to the knife or 
in which we may apprehend hemorrhage the galvano-cautery may 
be resorted to, applied under the guidance of the mirror behind the 
velum with the aid of the palate hook, the parts having been thor- 



ADENECTOMY. 



235 



oughly cocainized. We should endeavor in every case to remove 
or destroy the tissue as thoroughly as possible, and after the forceps 
and curette have been employed the parts should be explored for 




Fig. 89. Gottstein's Adenoid Curettes ; Showing Size and Shape of Blades. 



possible remnants or tabs of adenoid tissue still requiring atten- 
tion. 

The after-treatment consists simply in keeping the patient at rest. 
It is unwise and unnecessary to disturb him by any application or 
douching ; the drainage in this region is so perfect that indications 
of septic infection arc almost unheard of. A number of cases of 
hemorrhage and several of fatal bleeding after removal of adenoids 



236 DISEASES OF THE NOSE AND THROAT. 

have been reported by J. E. Newcomb and others, and serve to im- 
press upon us the importance of securing the history of all cases 
before operation as well as of careful attention afterwards. Chil- 
dren should not be permitted to sleep continuously for several hours ; 
they should be watched for any irregularity in the circulation. 
Should there be signs of persistent bleeding, after failure of at- 
tempts to check it by means of astringent irrigations of alum or 
tannogallic acid, the naso-pharynx should be firmly packed with 




Fig. 90. Author's Adenoid Forceps. 

gauze passed in through the mouth ; or the plugging may be accom- 
plished as it is performed for epistaxis. 

A combination of an alcoholic solution of tannin and antipyrin as 
a hemostatic was hit upon accidentally by Roswell Park, who speaks 
enthusiastically of its efficacy in a case of hemorrhage after removal 
of adenoids by F. W. Hinkel, as well as in bleeding in other situa- 
tions. It forms a gummy adhesive mass which clings closely to 
the part to which it is applied and makes a firm impenetrable tam- 
pon. The difficulty in removing it is the main objection to it, per- 
haps a minor one in general, but which applies to all tampons in 
cases of hemophilia. This point is very strikingly illustrated in 
cases described by A. A. Bliss. One of these, a case of deviated 
septum and adenoids, resulted fatally on the fourth day, recurrence 
of bleeding taking place on the slightest attempt to disturb the tam- 
pon. The obvious lesson is that all operative cases should be care- 
fully investigated beforehand for the possible existence of hemor- 
rhagic diathesis. It is a strange fact that some of the victims of 
hemophilia underestimate, or exhibit a moral perversity which leads 
them to conceal, their weakness, and our first intimation of its exis- 
tence may be the occurrence of bleeding after operation. It is prob- 
able that in the product of the suprarenal gland we have an antidote 



ACCIDENTS IN ADENECTOMY. 237 

to this condition more reliable than any hitherto possessed, but the 
fact remains that cutting operations in bleeders are better avoided. 

In the use of cutting instruments in the post-nasal space certain 
accidents may occur which may be obviated by the exercise of ordi- 
nary care. First, the margin of the velum may be lacerated by the 
blade of the forceps unless the instrument be passed well into the 
vault of the pharynx before being opened, the palate meanwhile 
being dragged forward by means of the left forefinger hooked behind 
it. Second, the edge of the vomer may be nicked if the handle of 
the forceps be too much depressed, not a serious matter but as well 
omitted. Third, the Eustachian cushion may be bruised or cut by 
carelessly tilting the instrument too much to one or the other side. 
Finally, a considerable flap of mucous membrane may be stripped 
from the posterior wall of the pharynx, which may be prevented by 
ploughing up the lymphoid tissue from below with the finger nail 
before applying the forceps, or by pressure with the finger tip at 
the lower limit of the adenoid mass while it is being torn from its 
attachments. While these incidents are usually of minor impor- 
tance, on the other hand they may become somewhat embarrassing 
complications and prolong convalescence. 

Inflammation of the middle ear is an occasional sequel of adenec- 
tomy and is most liable to occur in those who have already suffered 
from aural complications. Children who have had otorrhea, or 
been subject to earache, should receive special attention as regards 
precaution against exposure after operation. A very curious phe- 
nomenon has been observed in several cases after removal of lym- 
phoid hyperplasia and may be referable to excessive energy in the 
use of the curette or forceps, or to some peculiar neurotic state of 
the patient, namely torticollis, a complication developing two or 
three days after operation and subsiding in the course of a week as 
the wound gradually heals. 

The question is often asked as to the probability of relief of 
symptoms and of recurrence after removal of adenoids. In a large 
proportion of cases the relief is immediate and marked. Patients 
who have previously disturbed the household by noisy breathing at 
night will sleep so tranquilly as to excite the alarm of anxious 
parents. In certain individuals, however, in whom the habit of 



238 DISEASES OF THE NOSE AND THROAT. 

mouth breathing is firmly established and in whom, also, the parts 
are ill developed from prolonged disuse, nasal respiration is not 
immediately free. Under these circumstances we are sometimes 
obliged to resort to measures for closing the mouth during sleep and 
aiding the patient to learn the use of the nose for breathing. A 
shield worn within the lips or simply binding up the chin will gen- 
erally answer the purpose. Recurrence of adenoids may take place, 
even after thorough removal, especially when the operation has been 
performed early in life, in children of pronounced lymphatic ten- 
dencies. In many, however, it must be admitted that relapse is due 
to incompleteness of the operation, or to a coexistent obstruction 
within the nasal cavities. The last mentioned factor is of the utmost 
importance and in all cases of adenoids at any period of life nasal 
stenosis which is always productive of a state of hyperemia and 
favors the reformation of lymphoid tissue should be remedied. 

In older children and adults general anesthesia is not requisite. 
With cocaine and a large curette the operation may be done at one 
sitting, which is by most considered preferable to frequent repeti- 
tions of a performance always uncomfortable and often painful. 
In manageable subjects the forceps may be used with the aid of a 
palate hook and under the guidance of the mirror. This is really 
the most satisfactory and precise mode of operating, but is seldom 
found to be applicable, and we are compelled to rely upon the tactile 
sense in determining the character and distribution of the vegeta- 
tions. The fossa? of Rosenmuller as regards the ears, and the 
choanal, as regards breathing, are critical situations and are most 
effectively and safely reached with the forefinger, or, in case the 
operative field can be seen, with a small curette. Neglect of the 
latter region is a prominent cause of failure in the operation. 
Masses of lymphoid tissue may be crowded into the nares by the 
forceps or curette, or may be actually attached at some point ante- 
rior to the choanse. Hence the suggestion of Ingals to clear out the 
posterior nares by means of nasal cutting forceps passed from the 
front is valuable. Or possibly a small ring knife may be of service 
in this situation. In any case to give the best results the operation 
must be thorough, every vestige of morbid tissue being sought for 
and removed. No doubt it is possible for any one to pass a curette 



ADENOIDS. 239 

into the nasopharynx and scrape away more or less tissue, but this 
is not adenectomy as it should be done and tends rather to bring 
the operation into disrepute owing to incomplete relief and recur- 
rence of symptoms. Properly done there is no procedure in the 
domain of rhinology more prompt and satisfactory in its effects. 



CHAPTER XIII. 



HVPERTROPHIED TONSILS. 



Hypertrophied tonsils appear in two forms : the hard or fibrous 
tonsil which results from repeated attacks of acute, or subacute, 
amygdalitis, and the soft, or adenoid, which is the more frequent 
variety and occurs earlier in life. The former is apt to be accom- 
panied by more or less chronic pharyngitis, and to persist after 
puberty, marked examples having been observed in advanced life. 
The second variety of hypertrophied tonsil is almost always asso- 
ciated with lymphoid hyperplasia in the nasopharynx, as well as at 
the base of the tongue. In other words, the hypertrophy includes 
what has been called " the lymphoid ring," or " ring of Waldeyer." 
The mucous membrane of the follicles, rather than the parenchyma 
of the tonsil, is affected. The tonsils may be excessively enlarged 
only when acutely inflamed. They atrophy earlier and more com- 
pletely than the hard variety, but frequently the former merge by 
slow gradations into the latter in consequence of repeated attacks of 
inflammation resulting in the formation of new connective tissue. 
The hard tonsil is hyperplastic, the stroma of the gland being devel- 
oped by the growth and proliferation of connective tissue. The sec- 
ond form of enlarged tonsil is a genuine hypertrophy, the glandular 
tissue being mainly involved. 

From a clinical standpoint with special reference to treatment we 
may divide enlarged tonsils into three varieties : first, those whose 
size interferes with deglutition or respiration ; second, flat tonsils not 
especially enlarged but prone to recurrent attacks of inflammation 
and frequently the foci of suppurative inflammation, the formation 
of pus taking place not necessarily in the body of the tonsil, but in 
the adjacent tissue ; third, a class of tonsils in which there may be 
little or no apparent hypertrophy or encroachment upon the pharyn- 
geal space because of adhesions of the pillars to the surface of the 
organ as a result of repeated attacks of inflammation. Thus the 
tonsil, in the process of hypertrophy, carries with it the palato- 

240 



HYPERTROPHIED TONSILS. 24 1 

glossal fold which may be spread out over its surface as a thin veil ; 
or, the anterior pillar may be considerably thickened. In either case 
adhesions should be released if possible before attempts at reduction 
or removal of the gland are undertaken. Considerable shrinkage 
of the tonsil is often observed to take place after this procedure and 
excision may not be necessary. As to the best way of removing the 
first variety there is but little room for discussion. The guillotine 
usually succeeds in excising nearly all of the gland, or quite enough 
to answer the purpose. In the third form also this instrument is 
available, at least after an adherent pillar has been set free. In the 
second form, in order to gain the best results and protect the patient 
against further trouble, it may be necessary to resect masses of lym- 
phoid tissue containing diseased follicles lying deep in the sulcus 
between the palatal folds, especially at their junction above — the 
supratonsillar fossa. 

The degree of enlargement varies greatly in different cases. 
There may be hardly perceptible swelling, although the crypts may 
be in a state of chronic disease, or the tumefaction may be so ex- 
treme as to bring the surface of the tonsils almost in contact. 

The disturbance excited differs to a surprising extent ; in neurotics 
moderate enlargement produces an excessive amount of discomfort; 
whereas, in phlegmatic subjects, an enormous hypertrophy seems to 
excite but trifling annoyance. Usually the hypertrophy is, more or 
less, symmetrical. In rare instances we find one tonsil large, the 
other being nearly normal. Should the latter condition exist we 
may have reason to suspect the existence of syphilis, or the develop- 
ment of a neoplasm. When the formation of connective tissue is a 
marked feature the surface of the tonsil is apt to be smooth, the 
crypts being, to a greater or less degree, obliterated. The tonsil 
looks dense, hard, and fibrous. The true hypertrophied tonsil, in 
which the lacuna are chiefly involved, is apt to be irregular in con- 
tour and even tabulated. 

The symptoms caused by hypertrophied tonsils are variable. 
There is no pain except when they are inflamed but there may be 
discomfort and a sensation like that caused by a foreign body, with 
desire to swallow and, at times, some dysphagia with tendency to 
regurgitation of fluids through the nose. Usually the development 
16 



242 DISEASES OF THE NOSE AND THROAT. 

is very gradual and the surrounding parts seem to become accus- 
tomed to their presence. Reflex vomiting has been reported in some 
cases, and gastric disturbance is mentioned by many observers, either 
as a reflex neurosis, or from irritation of the alimentary canal by 
perverted secretions. Earache, impaired hearing and tinnitus 
aurium may be referable to the condition, but are much more likely 
to depend upon an associated lymphoid hypertrophy in the vault of 
the pharynx. The latter condition, also, is usually responsible for 
mouth-breathing and the heavy, stupid facial expression seen in 
children the victims of this anomaly. Reflex asthma and paroxys- 
mal cough are said to have been cured by ablation of these bodies. 
Enlargement of the tonsil is probably never congenital, although it 
has been met with at a very early period of life, and it is not unusual 
to find examples of it in several members of the same family. Those 
affected may be inclined to a strumous diathesis, or have a feeble 
constitution. But, on the other hand, we not infrequently meet with 
this condition in those who present no evidence of scrofulous taint 
or malnutrition. It rarely makes its appearance after maturity and, 
in many cases, we secure a history of previous attacks of acute in- 
flammation. It is a curious fact that, in some cases in which re- 
peated attacks of tonsillitis occur, there is no decided increase in the 
size of the tonsils ; while, on the other hand, we now and then see 
extreme hypertrophy without any history of, or special tendency to, 
acute inflammation. The damage caused by enlarged tonsils includes 
not only the immediate neighborhood of the pharynx but the general 
health. In addition they play an important part in the matter of 
infection and are a serious complication in the event of contagion. 
They are a source of constitutional disease by the mechanical impedi- 
ment they offer to respiration and by vitiation of the inspired air 
resulting from decomposing secretions incarcerated in their diseased 
lacuna?. In addition we observe that various reflex disturbances may 
be referred to them. Yet, in spite of the mass of evidence against 
them, we still hear the advice given to allow the patient to outgrow 
the condition. There is no valid excuse for such advice. While a 
child is outgrowing the enlargement he is exposed to all the dangers 
that have been recounted, whereas, under modern methods of operat- 
ing, the risks of surgical interference have been reduced to a mini- 



HYPERTROPHIED TONSILS. 243 

mum. The danger attending their removal is far less than that 
involved in the retention of diseased or hypertrophied tonsils in the 
pharyngeal cavity. The improvement in general health and in the 
local conditions, which almost invariably follows removal of the 
offending bodies, is sufficient argument in favor of the operation. 

Treatment. — The constitutional treatment of enlarged tonsils by 
itself is seldom satisfactory. The best of hygiene, and diet, and the 
use of the most powerful tonics are not capable of eradicating the 
fibrous tonsil. Nevertheless, anything which tends to improve the 
general health should be employed as an adjunct to local treatment. 
In some instances, a soft tonsil may be reduced to some extent by 
the use of astringent applications, or interstitial injections of iodine 
or corrosive acids. Massage of the tonsil has been recommended 
by many and seems to have been used with success in some cases. 
The process of absorption may be assisted by compression of the 
tonsil between the fingers, and electrolysis has been resorted to for a 
similar purpose. But these methods are all tedious and seem to be 
justifiable only in case of contraindication of more radical surgical 
measures. As to the latter it becomes necessary to determine what 
method of operating may be best adapted to a given case, as well as 
what may be the best time for operating. The suggestion is some- 
times made that it is better to postpone interference until some im- 
provement in the general condition may be secured. I have never 
seen reason to consider interference premature even in children who 
appeared to be in extremely poor general condition. It is not wise 
to operate upon a tonsil when it is acutely inflamed, although it has 
often been done and is still advised by some. The pain, the subse- 
quent reaction, and the hemorrhage are apt to be unusual under 
these circumstances ; nevertheless, we should not hesitate to inter- 
fere in case of threatened asphyxia from extraordinary swelling. It 
is injudicious to operate during the prevalence of an epidemic of 
scarlet fever or diphtheria, and indeed some go so far as to interdict 
the operation in a general hospital. In view of the startling fre- 
quency with which the Klebs-Loeffler bacillus, not to mention other 
septic organisms, has been found by Lichtwitz and others on the sur- 
face of a tonsillotomy wound such advice may not seem misplaced. 
The mode of operating depends upon the- shape, the size and the 



244 DISEASES OF THE XOSE AXD THROAT. 

relations of the tonsil. The best method of removing the tonsil as 
a rule is with the amygdalotome ; but. in certain cases, owing to the 
peculiar shape of the organ we shall be obliged to resort to other 
methods ; for the latter reason, or in consequence of a fear of hemor- 
rhage, which is justified in some cases, we may be compelled to select 
a bloodless substitute for the knife. Various chemical caustics have 
been tried with more or less success. Nitrate of silver, fused on a 
probe and passed into the crypts, chromic acid applied in a similar 
way or inserted into the body of the tonsil through small incisions 
and London paste applied to the surface of the tonsil with a spatula, 
have given some degree of satisfaction. These agents have to be 
reapplied at short intervals according to the amount of execution 
they do and the degree of reaction that follows them. Ignipuncture 
with Paquelin cautery and the galvano-cautery are much more ener- 
getic and precise agents, and in proportion to their greater effective- 
ness they are more painful and are followed by more intense reac- 
tion. In a trained, tolerant patient, after application and interstitial 
injections of cocaine, the whole tonsil may be destroyed with the 
electric cautery at a single sitting (Cullen) ; but, with a view to the 
patient's subsequent comfort, it is well to be satisfied with partial 
destruction of the gland at one time, accomplishing its complete 
removal in numerous sittings. Galvano-cautery puncture is well 
adapted to flat embedded tonsils, the removal of which with the 
knife or guillotine is difficult or impossible. It is a good plan to 
select three or four adjacent crypts and cauterize them in succes- 
sion, the cold electrode being passed to the bottom of the crypt and 
brought out hot to the surface of the tonsil. In this way large seg- 
ments of tonsillar tissue may be destroyed and there is little or no 
danger of retention of sloughing tissue which may become a focus 
of suppuration. It should be noticed that the electro-cautery method 
of dealing with enlarged tonsils is objected to on the ground that it 
leaves a large uneven surface and a sensitive cicatrix. It is believed 
that these objections are not well founded. If the electro-cautery 
is used with discrimination there is no reason why a perfectly 
smooth, insensitive stump should not be left by it as well as after 
the cutting operation. As a matter of historic interest it may be 
mentioned that, at one time, enucleation of the hypertrophied tonsil 



HYPERTROPIIIED TONSILS. 



245 



by means of the finger was the recognized 
method of operating. At the present day 
it must be considered obsolete, although it 
has been quite recently recommended by 
Lambert Lack. He holds that it is espe- 
cially adapted to small flat tonsils and that 
the gland can be enucleated completely and 
comparatively without loss of blood through 
an incision of the mucous membrane not 
penetrating the capsule and just behind the 
anterior pillar. The cold-wire snare is still 
a popular instrument in the hands of some 
operators. It is necessary to have a power- 
ful instrument and considerable time should 
be consumed in cutting through the base of 
the tonsil in order to obviate the danger of 
hemorrhage (Fig. 91). The usual precau- 
tions as to diet, exercise, etc., should be 
observed as a prevention of secondary hem- 
orrhage. There is sometimes difficulty in 
adjusting the loop of the cold-wire snare 
around the base of the tonsil which may be 
overcome by dragging the organ from its 
bed by means of a tenaculum or vulsellum 
forceps. In adults with prominent tonsils 
somewhat constricted at their base, and 
in children under general anesthesia 
this is a most excellent way of oper- 
ating. 

The hot-wire snare offers advantages over 
the cold-wire in completing the section much 
more easily and rapidly and in providing 
greater security against hemorrhage. We meet here, also, with 
difficulty in engaging the tonsil in the wire loop which the author 
has endeavored to overcome by constructing a loop-adjustor or elec- 
tric tonsil-snare. It is an adaptation of an idea proposed by Toison 
for the cold-wire ecraseur and consists of a double canula carrvine 



246 DISEASES OF THE NOSE AND THROAT. 

the wire and attached to a solid steel shaft from which it is insulated 
(Fig - . 92). The shaft ends in a ring whose vertical diameter is 
longer to correspond with that of most tonsils. The ring may be of 
different sizes. In using the instrument the wire loop is shaped to 
adapt itself to the ring to which it is fastened by a fine thread. The 
ring having been carried over the tonsil with the loop towards the 
median line, traction is made so as to bring the wire in contact with 
the tonsil above and below ; at this instant, the current being turned 
on, the wire burns through the thread which holds it to the ring. 
The loop buries itself in the tonsil and is no longer in danger of 
slipping. The advantages of this instrument are that the loop can 
be carried well over the base of the tonsil and the soft parts are held 
away by the ring and protected from the heat of the current. In 




Fig. 92. Author's Electric Tonsil-snare 



using electricity it is to be always remembered that the heat must 
be allowed to do the work and should not be excessive. Traction 
should be made upon the wire only when it is cool. Thus traction 
and burning are to be made in alternation. In spite of the absence 
of hemorrhage at the time of operation there are now on record sev- 
eral cases of secondary hemorrhage, hence excessive use of the voice 
and hard food should be prohibited until the eschar has completely 
separated. 

The total result of the operation is not limited to the tissues actu- 
ally removed, the parts left behind being cauterized to a considerable 
depth. The pain of the operation itself may be almost completely 
abolished by parenchymatous injections of cocaine, or nirvanin, a 
chloride of orthoform which has a very great advantage in being 
practically nontoxic. The latter is much less poisonous than cocaine, 
and moreover its analgesia is more prompt and prolonged. It has 
decided antibacterial properties, hence its solution may be kept ster- 
ile, or may be made so by boiling without damage, and there is no 
possibility of septic infection from its use hypodermically. It does 
not act through the unbroken skin or mucous membrane, and for this 



HYPERTROPHIED TONSILS. 247 

reason cannot be substituted for cocaine in superficial use. A one 
half or at most a two per cent, solution is found to be strong 
enough. 

Obviously the electro-cautery loop method of treating enlarged 
tonsils is adapted only to adults, or to children under general anes- 
thesia, and to protuberant tonsils. It cannot be used with flat deep- 
seated tonsils. The reaction is always considerable but may be con- 
trolled in a measure on general principles. It is a good plan to 
remove at one sitting but one tonsil, the second being attacked at the 
expiration of a week or ten days. Yet at the solicitation of the 
patient I have several times removed both tonsils in succession and 
have never had reason to regret having done so. In a recent case 
in which two enormous tonsils were excised with the cautery loop 
after interstitial injection of nirvanin the patient, a sturdy girl of 
thirteen, declared that the operation was painless and she had sur- 
prisingly little subsequent suffering in spite of the great extent of 
burned surface. 

There are four conditions which justify the use of the electric 
cautery as a substitute for a cutting operation : ( i ) Hemophilia ; 
(2) vascular anomalies; (3) peculiarity in the shape of the tonsil, 
and (4) refusal on the part of the patient to submit to the knife. 

A patient known to be a bleeder should never be cut. 

Among the vascular anomalies, a misplaced ascending pharyngeal 
artery or a large vessel in the margin of the anterior pillar, may be 
wounded by the knife. Injury to the plexus of veins at the lower 
border of the tonsil may give rise to hemorrhage ; and an abnormally 
large tonsillar artery frequently bleeds freely. It is sometimes im- 
possible to tell from the appearance of the tonsil whether hemor- 
rhage may be expected ; a very vascular looking tonsil often bleeds 
but little. In my experience this accident has occurred usually in 
adults with the hard fibrous tonsil in which the section has been 
made near the middle of the gland where the blood-vessels do not 
readily retract in consequence of a preponderance of new connective 
tissue. In the opinion of A. A. Bliss the tonsillar artery itself is 
seldom cut, unless the excision be very complete, which he concludes 
is rarely if ever necessary. This view is also held by Damianos, 
who in reporting a fatal case in a hemophile states that about 150 



248 DISEASES OF THE NOSE AND THROAT. 

cases of severe bleeding after tonsillotomy are on record, seven of 
which were fatal. His objection to complete removal seems to be 
based on the idea that the tonsillar artery is so embedded in the 
inelastic fibrous capsule of the gland that its severed end is prevented 
from contracting. 

Anatomical peculiarities comprise the flat or embedded tonsil, the 
so-called " submerged " tonsil, which cannot be included in the ring 
of the guillotine and with which the use of the knife or scissors is 
tedious and possibly dangerous. Adhesion of the anterior pillar, 
in this situation described by Harrison Allen as the " opercular fold," 
and the advisability of its detachment have been already referred to. 
Several cases of violent bleeding have followed section of this fold. 
Yet if the pillar is very thin, evidently consisting only of mucous 
membrane, and encloses no blood-vessel of importance, its existence 
may be disregarded and the blade of a tonsillotome be carried di- 
rectly through it, provided the tonsil protrudes sufficiently to allow 
the ring of the guillotine to surround it. In tonsils of this class 
electro-cautery puncture is generally the most satisfactory method. 

Although we call this a bloodless method of operating, a more 
extensive experience has demonstrated that it is not absolutely free 
from the risk of bleeding. A number of cases are on record in 
which an alarming hemorrhage has taken place on the fourth or 
fifth day from violent detachment of the eschar, as a result of ex- 
citement in laughing, or crying, or of laceration by a morsel of hard 
food. Ordinary caution in these particulars should ensure protec- 
tion against the accident. The operation itself may be rendered 
comparatively painless by local anesthesia, yet there is doubtless 
more reaction after burning than cutting. The fauces should be 
first thoroughly cleansed with an antiseptic spray and the surface of 
the tonsil swabbed with a ten per cent, cocaine solution. Then with 
an ordinary hypodermic syringe six or eight minims of a two per 
cent, solution of nirvanin are injected into the upper and an equal 
quantity into the lower part of the tonsil. In about three minutes 
anesthesia will be quite complete. 

In a large majority of cases the operation of choice is one of the 
various cutting methods. Most tonsils can be removed with the 
knife more quickly and thoroughly than in any other way, and the 



HYPERTROJ'HIED TONSILS. 



249 



resulting wound is less irritable and heals more kindly than one left 
by a caustic. The accepted instrument for use in cutting operations 
is a modification of Physick's tonsillotome, proposed several years 
ago by Morell Mackenzie (Fig. 93). Many so-called improvements 
have been suggested which complicate the instrument and add to the 




Fig. 93. Mackenzie's Tonsillotome. 

difficulty of the operation. Mackenzie's amygdalotome recommends 
itself for its strength, its simplicity, its safety and its efficiency. 
Rightly used it is capable of ablating almost the entire tonsil and 
that without endangering the large blood-vessels in the cervical re- 
gion. In certain cases a forked guillotine, like that of Mathieu 
(Fig. 94), may be serviceable. Spear or fork attachments have 




o 



TT^ 



Fi.:. 



My 



:ieu's Tonsillotomy 



been known to catch in the ring and in several instances a guillotine 
has thus been broken, either as a result of faulty construction or 
awkward manipulation. Some operators still prefer a stout bistoury 



250 



DISEASES OF THE NOSE AND THROAT. 



or scissors, but their use is far from easy in a field obscured by blood 
and constantly shifting with muscular contractions. It is sometimes 
difficult to remove the morbid tissue thoroughly and tonsil punches 
in a variety of shapes have been devised for the purpose of reaching 
the bottom of the tonsillar fossa. In order to protect the patient 
against recurrence of circumtonsillar phlegmon it is quite important 
to remove these deep-seated masses. Morcellement, or ablation of 
the tonsil by crushing with powerful flat-bladed forceps followed by 
excision of the crushed portion, called by Ruault " amygdalothrip- 




Fig. 95. Farlow's Tonsil Punch. 



sis," is said to be a satisfactory way of disposing of these hypertro- 
phies. The tonsil punch is adapted to cases in which the knife is 
impracticable (Fig. 95). In this connection a very curious and hap- 
pily rare anomaly may be mentioned as offering an obstacle to 
removal of a tonsil, namely an elongated styloid process. It has 
been met with by G. L. Richards, who was obliged to divide the 
bone with cutting forceps before the section of the tonsil could be 
completed. In several instances a lacunar concretion, or tonsillith, 



HYPERTROPHIED TONSILS. 25 I 

has been found to impede the passage of the knife blade. Such 
conditions are more likely to occur in adults than in children and 
are extremely infrequent at any age. 

It has been said that excision of the tonsils is the only operation in 
the upper air track requiring the exercise of brute force, and it is 
certainly true that failures in the management of the Mackenzie 
instrument result from the use of too light a hand. Firm outward 
pressure with the forefinger on the shaft of the guillotine must be 
kept up while the blade is being closed. Otherwise the ring tends 
to slip off and with a mere shaving of mucous membrane. The 
expression " brute force " needs to be modified by the adjective 
" reasonable." I have seen a muscular young athlete tear a large 
rent in the posterior pillar by the exercise of too much energy. In 
this connection it might be mentioned that a mouth-gag is not needed 
in adults and without an anesthetic, and that a tongue depressor is 
always superfluous, the guillotine itself acting in that capacity. The 
remarkable feat of amputating a uvula and excising a tonsil at the 
same time has been accomplished by introducing a guillotine upside 
down, the handle pointing upwards, a most unnatural and awkward 
position not to be recommended. 

It is my custom to excise both tonsils at one sitting, the left one 
first and then the right. Double guillotines intended to cut both 
at once are awkward and unreliable. If the operation can be done 
without an anesthetic the patient sits facing a window, his head rest- 
ing against the body of an assistant whose hands should steady the 
head and epecially support the tonsil about to be excised. It is 
unnecessary and perhaps dangerous to try to force the tonsil inward 
by external pressure with a single finger. Reliance should rather 
be placed upon the act of gagging and firm outward pressure with 
the instrument to force the gland within its grasp. In removing the 
left tonsil the handle of the instrument should be held in the opera- 
tor's right hand. The shaft, the blade being open, is passed over 
the dorsum of the tongue, turned quickly so as to bring the fenestra 
over the tonsil, and pressed firmly outward with the forefinger of 
the left hand. This pressure upon the shaft of the instrument and 
the act of gagging provoked by the presence of the guillotine in the 
fauces, drive the tonsil well into the ring, advantage of which should 



252 



DISEASES OF THE XOSE AND THROAT. 



be taken to push the blade home with the thumb of the hand holding 
the instrument. Usually the excised portion of tonsil is held by 
shreds of mucous membrane in the groove of the ring. The instru- 
ment is quickly withdrawn, opened, and the manipulation repeated 
upon the right tonsil, the guillotine being held in the operator's left 
hand. Used in this way the Mackenzie instrument will be found to 
make almost a complete enucleation of the tonsil in most cases. It 
is customary to have pretty sharp bleeding for a few moments at the 
completion of the operation. In several cases an alarming secondary 
hemorrhage has taken place a considerable time after operation. For 
example, in one reported by Moure a week had elapsed. In one of 
the author's cases the bleeding occurred on the second and in another 
on the fifth day. Several times in my experience it has seemed wise 
to abandon a contemplated adenectomy on account of excessive loss 




Fig. 96. Butts' Tonsillar Hemostat. 

of blood from an excised tonsil. If the hemorrhage does not sub- 
side after the loss of a few ounces of blood it is time to consider 
measures for its arrest. In most cases the application of cold exter- 
nally and holding bits of ice in the mouth will suffice. If these fail, 
a mixture of tanno-gallic acid — one part of gallic and three parts of 
tannic, in the proportion of about twenty grains to the ounce of 
water — may be used as a gargle ; and small quantities of the solution 
may be swallowed ; the act of swallowing driving the styptic into 
the stump of the tonsil. Parenchymatous hemorrhage will almost 
invariably be checked by this procedure. Hemorrhage from a large 
tonsillar artery cannot be thus controlled and we then shall be obliged 
to resort to some other method. Direct pressure by the finger, or 
by means of one of the various tonsillar hemostats (Fig. 96), should 



HEMORRHAGE IN TONSILLOTOMY. 253 

be tried without wasting time over styptics (Fig. 97). Ligation of 
the tonsil after transfixing the stump with a tenaculum is sometimes 
feasible; but it is not easy to ligate a tonsillar artery from which 
brisk hemorrhage is taking place in a nervous frightened child, or 
even in an adult. The electric cautery, or Paquelin cautery will 
check persistent oozing but will rarely control an arterial jet. An 
ingenious proposition by Levis succeeded in an obstinate case under 
his care; the stump of the tonsil was transfixed by a tenaculum; it 
was then twisted to bring the flat handle between the teeth and the 
jaws were bandaged together ; on withdrawing the instrument next 
day there was no return of hemorrhage. When hemorrhage is to 
be apprehended from any source Seifert advises the use of the gal- 




Mikulicz-Stoerk Tonsil Hemostat. 



vanocautery snare in operating and suggests that one be content to 
remove not more than three fourths of the tonsil, the latter precau- 
tion, however, appearing somewhat superfluous in addition to the 
former. 

Ligation of the carotid artery for tonsillar hemorrhage has sev- 
eral times been done, but in at least one such case it seems clear that 
the bleeding was on the point of ceasing spontaneously. On ana- 
tomical grounds the external carotid, between its superior laryngeal 
and ascending pharyngeal branches, would be the vessel indicated 
for ligation, but in view of the fact that the importance of this acci- 
dent has been vastly overdrawn a less formidable procedure would 
seem to be preferable. If a stump of tonsil has been left the loop 
of a cold-wire snare may be passed over its base and gradually tight- 
ened, or if the excision has been complete the tissues may be trans- 
fixed with a needle in a long handle and the wire slipped over its 
ends. A very ingenious device by Dawbarn consists in surrounding 
the bleeding area with a submucous ligature, or " purse string " liga- 
ture, passed in four directions. A double-curved needle in a holder 



2 54 DISEASES OF THE NOSE AND THROAT. 

and loaded with a stout ligature of silk or catgut is passed from 
before backward beneath the bleeding point, then vertically upward 
behind it, then directly forward and finally downward to the spot 
where the needle first entered. The pillars need not be included by 
the ligature which is practically buried at all points and may be 
allowed to slough out or may be removed after two or three days. 
In most cases a tonsillar hemorrhage, if allowed to take care of itself, 
will cease spontaneously on the supervention of faintness with de- 
creased blood pressure, and the last remedy used gets the credit of 
having checked the bleeding. This may not be an agreeable mode 
of controlling a hemorrhage, but the episode is robbed of most of 
its terrors when the patient can be assured that nature's way of 
stopping a leak in a blood-vessel is usually effective. The results of 
careful study of this subject made by Lefferts have been amply con- 
firmed by others. His conclusions were ( i ) that a fatal hemorrhage 
after the operation of tonsillotomy is very rare; (2) a dangerous 
hemorrhage may occasionally occur; (3) a serious one, serious as 
regards both possible immediate and remote results, is not very 
unusual ; and (4) a moderate one, requiring direct pressure or strong 
astringents to check it, is commonly met with. My own experience 
with alarming hemorrhage is limited to four cases, two in adults and 
two in children under ten years of age. In all the guillotine was 
used. In the case of the children the bleeding ceased spontaneously 
after the failure of several domestic measures and when exsanguina- 
tion had become extreme. A similar course was followed with the 
adults, although in one of the latter direct pressure seemed to be of 
some service, while in the other efforts to stop the flow by torsion 
and electric cautery were unsuccessful. 

The use of general anesthesia in removing tonsils has been the 
subject of much discussion. The pain of cutting or burning may 
be mitigated in some degree by the application of cocaine, or the 
parenchymatous injection of cocaine or nirvanin. It has been sug- 
gested that cocaine increases the liability to secondary hemorrhage, 
but there is no good foundation for such an assumption. General 
anesthesia seems to me, by all means, more humane, especially in 
young children, in spite of the opinion of many authorities that it 
is wholly uncalled for. The argument offered against it generally 



HYPERTROPHIED TONSILS. 255 

is that it deprives us of the assistance of the patient in preventing 
the admission of blood to the air passages, which is not strictly true 
if the anesthesia be not profound. Cases of fatal asphyxia are on 
record from the entrance of blood into the larynx during tonsil- 
lotomy under chloroform. Some maintain that anesthetization ex- 
cites as much resistance as attempts to excise the tonsil without it. 
My own position is that if given in a proper way, in suitable quan- 
tities, ether will be found on the whole the most satisfactory and 
certainly the safest anesthetic. If the administration of ether is 
preceded by inhalations of nitrous oxide gas, a very moderate quan- 
tity of the former is required, the unpleasant suffocative effects of 
ether are obviated, the reflexes are not abolished, and the after 
effects are much reduced in unpleasantness. By giving a general 
anesthetic in this way we do not involve any greater risk, we save 
the patient much nervous shock, we permit ourselves much better 
opportunity to examine the case carefully and especially to explore 
the naso-pharynx, which is always a most important thing to do, 
and if any morbid condition is found there it may be relieved at 
the same time. It is best to remove the faucial tonsils first in suc- 
cession, the mouth being held open by a mouth-gag; the patient is 
then turned upon the side or a little upon the face to permit the 
blood to drain from the mouth, and, after the hemorrhage has sub- 
sided, he should be replaced upon the back and a rapid exploration 
made of the vault of the pharynx with the forefinger. It may be 
necessary to give a little more ether when this additional step is 
taken. 

It seems to be a fact that the danger of hemorrhage after the 
removal of a tonsil has been much exaggerated. The number of 
cases of excessive bleeding on record in proportion to the number 
of tonsils removed is extremely small. Nevertheless, especially in 
adults, the possibility of its occurrence should be borne in mind, 
and before the operation is undertaken the patient should be thor- 
oughly informed and, if an adult, should be, in a measure, allowed 
to select the mode of operation. 

The question of the advisability of removing enlarged tonsils 
seems to be no longer open. Their injurious effects are so obvious, 
the benefit following their removal is so apparent, and the risks of 



256 



DISEASES OF THE NOSE AND THROAT. 



the operation arc so slight, that there should be no hesitancy in 
advising it when the necessity arises. We should endeavor to re- 
move as much of the morbid tissue as possible, in other words to do 
a " tonsillectomy." and in order to accomplish this it may be neces- 
sary in exceptional cases to dissect out the deep-seated masses with 
blunt scissors or tonsil knife (Fig. 98), rather than undertake to 
use the amygdalotome. It is not sufficient to make a superficial 
section for the reason that a remnant of tonsillar tissue containing 
diseased follicles is very prone to become the subject of an acute 
inflammatory process under circumstances which excited its occur- 
rence before operation. It rarely happens that the faucial tonsil 
reproduces itself after radical excision. In very young subjects 
with a tendency to lymphoid hypertrophy there may be possibly a 




Fig. 98. Tonsil Knives. 

slight inclination to recurrence. But, as a rule, we find that the 
improved general condition following a nearly complete extirpation 
results in progressive shrinkage of what small stump may be left. 
On the other hand in certain cases a moderate growth of lymphoid 
remnants may take place precisely as in the case of adenoids in the 
pharyngeal vault. Yet the experience of Coakley, who states that 
he did amygdalotomy four consecutive times within as many years 
on tlie same patient, is most extraordinary. 

Three questions are almost invariably asked whenever a tonsil- 
lotomy is proposed ; whether there is any risk from hemorrhage or 
other sources, second, if the tonsils are likely to grow again, and 
finally what effect if any their removal may have upon the voice or 
other bodily function. The first two have perhaps been sufficiently 
discussed. A fear of sexual impairment sometimes suggested is 



HYPERTROPHIED TONSILS. 257 

based upon a process of reasoning similar to that which discovers 
in suicidal mania a direct result of excision of the tonsils because 
two or three individuals are reputed to have taken their own lives 
shortly after having been cut. The question of damage to the voice 
deserves to be treated more seriously and is more important espe- 
cially in those whose livelihood or enjoyment of life may be in- 
volved. At intervals this objection finds expression in medical lit- 
erature. Personally I have never experienced a case which gave it 
a shadow of foundation. At first there is almost always a startling 
change in the quality of the voice which may disturb the patient and 
distress his friends, but this passes away in a few weeks at most, 
and is succeeded by marked improvement in fulness and resonance 
as he learns to modulate his voice and adapt his palatal muscles to 
their new relations. 

A curious post-operative phenomenon, at times possibly leading 
to confusion and even alarm, merits passing notice, namely " tonsil- 
lotomy rash." It is extremely rare, having been mentioned only by 
Lennox Browne and one or two other writers, but has recently been 
described anew by Wyatt Wingrave and E. A. Forsythe. It may 
occur as a papular, roseolar or erythematous eruption, usually begin- 
ning on the neck, chest and abdomen and thence extending some- 
times to the extremities. It may be attended by considerable itch- 
ing, but disappars in two or three clays without desquamation and 
with little or no constitutional disturbance. Its occasional occur- 
rence should be kept in mind with a view to escaping a possible dis- 
quieting error in diagnosis. 

In conclusion no good reason can be offered for allowing the ton- 
sils to remain when they are clearly proved to be causes of local as 
well as systemic derangement, and no method of removal other than 
surgical is worth considering, except in those very rare conditions 
which have been enumerated. 



CHAPTER XIV. 

DISEASES OF THE LINGUAL TOXSIL. ABSCESS OF THE TONGUE. 
RETROPHARYNGEAL ABSCESS. MYCOSIS OF THE PHARYNX. 

HYPERTROPHY OE THE LINGUAL TOXSIL. 

The lingual tonsil is composed of tissue analogous in all respects 
to the lymphoid tissue situated between the palatal folds and in the 
vault of the pharynx. This tissue exhibits similar pathological 
changes wherever found and in its enlarged state at the base of the 
tongue causes peculiar symptoms which are very apt to be misin- 
terpreted. "When we consider that hypertrophy of the lingual ton- 
sil must impede the action of the epiglottis and the movements of 
the tongue it is easy to understand how functional disturbances may 
result. It is a notorious fact that changes in the lymphoid tissue in 
this situation are often met with late in life and in the female sex. 

The symptoms which it causes vary greatly in different persons. 
They are dependent not so much upon the degree of the hypertrophy 
as upon the temperament of the individual. A moderate amount of 
hyperplasia, in some cases, will excite an extraordinary degree of 
disturbance. A sense of fulness and tickling in the throat and a 
constant desire to clear the passages by the act of hacking or cough- 
ing are most often complained of. The condition is a serious one 
in those who use the voice, either in singing or public speaking. 
The effort to overcome the mechanical obstacle offered by a mass 
of lymphoid tissue at the base of the tongue may demand the exer- 
cise of muscles which should not be employed in voice formation ; 
and, in consequence, the patient soon becomes hoarse and tired, and 
may actually lose his voice for a time. Finally structural changes 
may be engendered in some part of the vocal apparatus productive 
of partial or complete aphonia. Reference has already been made 
to the morbid conditions of the vocal bands met with under these 
circumstances. A number of reflex symptoms have been detailed 
in the line of neuralgic pains, asthmatic attacks, spasm of the glot- 

258 



HYPERTROPHY OF THE LINGUAL TONSIL. 259 

tis, etc., which are comparatively rare occurrences. R. Levy divides 
these cases into six classes. First, those attended merely by dis- 
comfort, or paresthesia. Symptoms may have been excited and the 
mind of the patient fixed upon this locality by swallowing a foreign 
body or a rough particle of food, and the patient seeks to be relieved 
of something which he imagines is still sticking in his throat. Some 
of these people consult a physician because they apprehend cancer 
or tuberculosis. In a second class cough is a very persistent and 
distressing symptom, which is only temporarily controlled by seda- 
tives, but yields promptly after the use of the galvanocautery in 
adults and in children to swabbing with tincture of iodine and gly- 
cerine. Third, dysphonia, vocal fatigue, throatache and impure tone 
production may be especially noted in singers, to whom these condi- 
tions are of the utmost moment. Fourth, dyspnea, resembling that 
caused by spasm of the larynx and occurring chiefly at night, may 




Fig. 99. Hypertrophy of Lingual Tonsil. (Griinwald.) 

be so extreme that the patient dreads going to bed, and eventually 
the general health may suffer from loss of sleep and mental distress. 
Fifth, dysphagia may exist to a degree sufficient to impair nutrition, 
and sixth, hemorrhage may occur from an associated lingual varix. 
The last is certainly rare. Nevertheless in view of the extreme dis- 
quietude caused by the appearance of blood in the sputa it may be 
a satisfaction to be able to assure a patient that it comes from the 
base of the tongue and not from the lungs. 

The diagnosis is usually made without difficulty by simple inspec- 
tion with the laryngeal mirror (Fig. 99). [rregular masses of 



26o DISEASES OF THE NOSE AND THROAT. 

lymphoid hyperplasia, frequently covered with enlarged veins, may 
be seen which sometimes incarcerate the tip of the epiglottis. The 
masses are in some cases so large as to be distinctly pedunculated 
and may be visible without the mirror through the open mouth. 
Protrusion of the tongue fails to separate its base from the epiglot- 
tis. A most conspicuous feature in the picture is often the remark- 
able size and number of varicose vessels. Lingual varix may exist 
without much hypertrophy of lymphoid tissue. The presence of 
multiple turgid vessels should of course restrain us from the use 
of cutting instruments in this region. In elderly people lingual 
varix is very commonly observed and rarely possesses any signifi- 
cance. It may be associated with varicose vessels in other situa- 
tions. 

The symptoms may sometimes be relieved temporarily by paint- 
ing the region with cocaine. In many cases the condition is aggra- 
vated by impaired general health, neurasthenia, or deranged diges- 
tion. Improvement in these particulars under general medication, 
possibly combined with the local application of astringents, will 
often effect a cure. In other cases, the persistent cough and the 
phonatory disturbance demand more energetic treatment and we are 
compelled to resort to destruction of the masses by the use of caus- 
tics, or the electro-cautery, or to removal by means of the snare or 
the knife. The process of cauterization with electricity is painful 
and disagreeable while effective if persevered with. The knife in 
this region is a dangerous instrument for the reason that the parts 
are apt to be rather vascular and, moreover, it is not an easy place 
in which to control bleeding by pressure. The cold-wire snare is, 
perhaps, equally effective and certainly safer, but we need for this 
purpose an instrument of unusual power. Various lingual tonsil- 
lotomes have been proposed shaped very much like the guillotine 
used in excising the faucial tonsil, but somewhat curved to fit the 
dorsum of the tongue (Fig. ioo). The reaction from the operation 
of removing these masses is sometimes considerable, especially when 
the electro-cautery has been used, and is best relieved by holding 
pieces of cracked ice in the mouth, or by the application of cocaine. 

The lingual tonsil is no doubt subject to inflammatory attacks pre- 
cisely as are the other lymphoid masses in the " adenoid triangle," 



ABSCESS OF THE LINGUAL TONSIL. 26 1 

or " lymphoid ring." In the opinion of H. L. Swain, who has seen 
a number of cases, the condition is often overlooked. A series of 
sixteen cases has been reported by Seifert and almost an equal num- 
ber by other observers. They may be less frequent, or perhaps less 
clearly recognized, than similar affections of the palatal tonsils, or 
possibly the intensity of the process in the latter overshadows a con- 
comitant trouble at the base of the tongue. Phlegmonous inflam- 
mation, or " lingual quinsy " may be a very serious disease. It 
rarely extends beyond the anatomical limits of the tonsil, but when 
it does invade the floor of the mouth it resembles a true " angina 




Fig. ioo. Roe's Lingual Tonsillotome. 

Ludovici." The constitutional disturbance is extreme, as indicated 
by the high temperature and rapid pulse. Pain is severe and con- 
stant and is intensified by attempts to speak or swallow and by the 
slightest movement of the tongue. The swelling may be enormous 
so that the tongue protrudes from the mouth and there is a continu- 
ous dribbling of saliva. The breath becomes horribly fetid and 
the tongue is covered with a thick leathery fur. Dypsnea may 
result from swelling or from edema of the epiglottis and the vesti- 
bule of the larynx. The danger from this source, or from asphyxia- 
tion following a rupture of the abscess, is considerable, especially 
in the aged and in those weakened by long illness. 

It is difficult and may be impossible to introduce the finger for 
palpation, and even if we succeed a sense of fluctuation is very 



262 DISEASES OF THE NOSE AND THROAT. 

obscure and indecisive. We may be forced to make a diagnosis 
without even a glimpse of the parts involved. 

From this brief description it must be clear that this is a much 
more serious and alarming process than similar affections of the 
other tonsillar masses. Fortunately it is much more infrequent. 
Doubtless some of the cases of so-called " abscess of the tongue," 
and very likely the fatal cases of alleged " quinsy " should be classi- 
fied under this designation. 

The causes acting to excite inflammation of other lymphoid tissue 
operate equally in the case of the lingual tonsil. A depressed state 
of the general health, a rheumatic diathesis, or a foreign body may 
be concerned as factors in the causation of inflammation of the glands 
at the base of the tongue. An interesting example of the last- 
mentioned cause was observed by the author many years ago, in 
which a wisp of straw taken into the mouth with a draught of water 
became engaged in one of the lingual follicles. After several days 
of extreme distress the patient was relieved by spontaneous rupture 
of the abscess. 

The general treatment should be conducted on the lines laid down 
in speaking of the faucial tonsils. Early and free incision for the 
release of pus, and even if the presence of pus cannot be demon- 
strated, is clearly indicated. The best instrument for this purpose 
is a sharp-pointed curved bistoury with a rather short thin blade. 
Hemorrhage is apt to be very free. If an abscess is opened and pus 
evacuated the relief of symptoms is immediate, and in any case 
scarification does no harm. Hot alkaline and antiseptic mouth- 
washes and hot fomentations externally 'are usually soothing and 
grateful. The necessity for stimulating and supportive treatment 
may be urgent. 

Neoplastic formations and tumors in the region of the lingual ton- 
sil are rather uncommon. Among the most interesting of the latter 
may be mentioned accessory thyroid tumors, instances of which have 
been reported by H. T. Butlin, J. E. Schadle and others. A remark- 
able phenomenon in a case recorded by Schadle was presented in the 
form of vascular turgescence of the tumor during a period of sup- 
pressed menstruation. This growth was removed by McBurney by 
an external incision, its real nature not having been previously fully 



RETRO -PHARYNGEAL ABSCESS. 263 

determined. In a case reported by Theisen an accessory thyroid as 
large as a hen's egg was observed deeply embedded in the base of 
the tongue. It appeared to be quite vascular, which fact together 
with the patient's age (67) was thought to preclude operation. The 
tumor diminished somewhat in size under internal use of thyroid ex- 
tract. An interesting point in the history is that the woman had a 
goiter in early life, all trace of which had disappeared. 



RETRO-PHARYNGEAL ABSCESS. 

Retro-pharyngeal abscess is a phlegmonous inflammation involv- 
ing the cellular, or the lymphoid, tissues of the pharyngeal wall. In 
the majority of cases no cause for the suppuration can be discovered; 
in a few, it succeeds abscess formation in the cervical region ; in 
others, it is secondary to caries of the vertebrae; in a small propor- 
tion of cases it is a sequel of an exanthem ; and, finally, it may be 
produced by a foreign body. In a large number of cases, in chil- 
dren, the lymphoid tissues are evidently the seat of the disease and 
the course of the lesion is usually extremely slow. In adults, on 
the other hand, the abscess is more apt to simulate suppuration in 
cellular tissues elsewhere and is attended by more disturbance and 
local reaction. In children it is usually considered a sign of struma. 
Its development is very slow, the general health of the child becomes 
gradually impaired, food is refused as the difficulty in swallowing 
increases and, finally, a peculiar throaty quality of the voice becomes 
pronounced and there is more or less impediment to breathing. The 
dyspnea ultimately becomes very alarming and, in fact, may be the 
first symptom to draw attention to the throat. 

On examination the pharynx is seen to be occupied by a bulging 
tumor, usually upon one side of the middle line over which the 
mucous membrane is glazed and tense. Usually the tumor occupies 
the oropharynx but, in rare instances, it is much lower and may not 
be visible by direct inspection. In adults the local symptoms may 
be much more acute at the onset and there is more or less constitu- 
tional disturbance. Pain referred to the faucial region aggravated 
by swallowing directs attention at once to the throat. The obstruc- 
tion to swallowing may be so considerable as to interfere with nutri- 



204 DISEASES OF THE NOSE AND THROAT. 

tion. The breathing is seldom seriously impeded. The appearances 
presented resemble those of an abscess in other situations and the 
diagnosis of pus formation may be confirmed by palpation with the 
finger; a peculiar elastic sensation indicative of fluid and analogous 
to fluctuation may be readily recognized. 

If left to itself an abscess in this situation will usually discharge 
in a week or two ; but, in children, it sometimes runs a very chronic 
course, extending over many weeks. In the latter case, while the 
local disturbance may not be very serious, there is clanger that the 
patient may succumb in consequence of impaired nutrition. In chil- 
dren and in individuals very much reduced in strength, or advanced 
in years, spontaneous rupture of the abscess, or opening by incision 
may be attended by some risk from entrance of pus into the larynx. 
In milder cases, simple incision with a guarded bistoury and evacua- 
tion of the pus will result in cure. Erosion of an artery with fatal 
hemorrhage has occurred in several cases on record. Edema of 
the glottis is a complication of especial seriousness in weak children. 
In some instances of extensive suppuration external opening of the 
abscess may be required by an incision along the anterior border of 
the sterno-cleido-mastoid muscle. This more formidable operation 
is demanded only in cases of extraordinary extent, or where the 
abscess is seated low down in the pharynx. Ordinarily simple punc- 
ture or incision through the mouth under local anesthesia will suffice. 
In unmanageable children a small quantity of chloroform may be 
required. Local applications are useless since the formation of pus 
is generally inevitable and rapid and its evacuation is necessary. 
There is seldom necessity for special dressing of the abscess cavity. 
During convalescence a semi-fluid diet and the use of antiseptic 
sprays and gargles, especially after taking food, are plainly indi- 
cated. Attention should be given to the general health and the cor- 
rection of a strumous diathesis. 



PHARYNGO-MYCOSIS. 

Mycosis of the pharynx, first described by B. Fraenkel, is a term 
applied to a fungous development which sometimes appears upon the 
surface of the tonsil, upon the lymphoid tissue at the base of the 



MYCOSIS OF THE PHARYNX. 265 

tongue, or within the follicles distributed over the mucous membrane 
of the pharynx. The vault of the pharynx also is often invaded. 
It consists of a deposit of spores of the leptothrix buc calls, a fungus 
which is almost invariably present in the oral cavity and yet its 
transference to the fauces is comparatively rare. 

Impaired general health is usually regarded as a predisposing 
cause and, in a large proportion of those subject to it, digestive 
derangements are pronounced. In some cases the saliva is said to 
have an acid reaction. In a small number of cases it has been 
observed to follow tonsillitis and diphtheria, but there is no proof of 
any special relationship. In a large majority of cases the patients 
seem to be in perfect health, and absolutely no constitutional distur- 
bance is observed. 

The symptoms which it induces are not of very pronounced char- 
acter. It is not at all uncommon to discover deposits of mycosis in 
those who are unaware of any trouble whatever. Occasionally 
slight hacking cough and a feeling of irritation in the pharynx are 
present, but there is never acute local inflammation, except as a 
coincidence. The appearances it presents are almost unmistakable; 
yet it is not a rare experience to see cases that have been diagnosed 
and treated as follicular tonsillitis. Such an error may occur when 
the fungous growth is unusually exuberant, or is attended by inflam- 
matory conditions. The uniform absence of the latter and the color- 
less appearance of the exudate differentiate it positively from diph- 
theria. It occurs in the form of filamentous tufts projecting from 
the surface of the membrane, usually from a follicle, milky white in 
color. If one of these projecting masses be seized with the forceps 
it frequently may be drawn from the lacuna with ease. Sometimes 
its removal is followed by the escape of a little blood. The condi- 
tion is perfectly innocuous and spreads slowly. Having been re- 
moved by mechanical means or by destructive agents it frequently 
shows a marked tendency to recur. 

The treatment of the disease is very troublesome since success 
depends upon the complete and thorough destruction of all the 
spores; should any be overlooked they will be sure to reproduce 
themselves. A variety of agents have been employed, including 
absolute alcohol, perchloride of iron, pure carbolic acid, iodine prep- 



266 DISEASES OE THE NOSE AND THROAT. 

arations and ail the stronger astringents, but the galvano-cautery 
gives the best results. Large masses of lymphoid hyperplasia, which 
offer a favorable site for the development of the mycotic product, 
should be removed. The milder cases which give but very few 
symptoms may, very properly, be let alone, or be treated by simple 
antiseptic gargles and the correction of possible digestive distur- 
bances. The galvano-cautery and pyoctanin are relied upon by R. 
P. Lincoln in the treatment of this disease. The latter is used in 
powder rubbed briskly into the affected region daily until all signs 
of the growth disappear. Enlarged follicles, or hyperplastic masses 
of lymphoid tissue containing the tufts may be burned away with 
the electric cautery or excised. 

A membranous disease presenting the gross appearances of a gen- 
uine mycosis, according to Kyle and others, is a keratosis beginning 
in the submucosa. It is pronounced not bacterial, although the lep- 
tothrix has been found in certain cases, probably as an accidental 
occurrence. This is the view elaborated by Siebenmann, who 
maintains that the bacteria are purely saprophytic and that they 
are in no respect etiological. Similar conclusions are reached by 
Geo. B. Wood, who thinks that the peculiar formation of keratosis 
is the result of a low grade of inflammation sufficient to stimulate 
the growth of normal epithelium and not intense enough to lead 
to the pus formation of an acute process or the accumulation of 
the cheesy masses characteristic of a chronic lacunar amygdalitis. 
Brown Kelly expresses the opinion, based on an exhaustive study 
of the subject, that there are two distinct diseases, mycosis and 
keratosis, which present the following differences : 

i. Keratosis is found in adults, mycosis at any age. 

2. The cause of keratosis is unknown, mycosis is due to some 
derangement of buccal secretion or of the digestive tract, or possibly 
to a rheumatic or other diathesis. 

3. The symptoms of keratosis are slight or absent, those of myco- 
sis are pronounced. 

4. In keratosis the mucous membrane is normal, in mycosis in- 
flamed. 

5. The exudate of keratosis is tough, firmly adherent, and assumes 
characteristic shapes, that of mycosis is soft and easily detached. 



KERATOSIS OF THE PHARYNX. 267 

6. Keratosis affects only the tissues of Waldeyer's ring, mycosis 
may occur at any part of the mucous membrane. 

7. Keratosis, except for the presence of leptothrix, bears no re- 
semblance, while mycosis is similar to thrush, sarcina and other 
mycoses. 

8. Keratosis is not influenced while mycosis may be cured by local 
applications. 

These views are in a sense a compromise between Heryng's theory 
as to keratosis and that of Miller, who describes several different 
forms of bacilli as causative factors. According to the latter none 
of these organisms can be cultivated in any known media, while 
Jacobson claims to have cultivated the leptothrix on potato. The 
pathogenic nature of the leptothrix is thought to be proved by the 
fact that this organism was found by Pearce in two cases extending 
deeply into healthy tissues. Jonathan Wright believes that the thick- 
ening of the epithelial lining of the affected crypts is a result of a 
chronic inflammatory process caused by the irritative action of the 
mycelium. Similar phenomena are often observed in other parts 
of the air track. By staining sections of tissue containing the mycel- 
ium with gentian violet and Gram's iodine he was able to demon- 
strate the bacillus maximus buccalis as well as the leptothrix. He 
has been unable to confirm the observation that the mycelial threads 
sometimes penetrate the epithelial layer and even the subjacent tis- 
sues. On the contrary he has always found them only in the lacunae 
surrounded by innumerable spores. 

Thus there appears to be hopeless confusion as to the importance 
of the role played by the various organisms, and after all the lesion 
is of interest chiefly as a microscopic picture and not by reason of 
any marked clinical signs. 



CHAPTER XV. 

TONSILLITIS. DIPHTHERIA. CIRCUMTONSILLAR ABSCESS, OR QUINSY. 
ULCERO-MEMBRANOUS OR DIPHTHEROID AXGIXA. 

TONSILLITIS. 

Inflammation of the tonsil may involve the mucous membrane 
covering the gland, that lining the crypts, or the substance of the 
organ itself; the first is called superficial, the second, lacunar or fol- 
licular, and the last, parenchymatous amygdalitis. These are prac- 
tically stages of the same disease ; the last is frequently complicated 
by the formation of a phlegmon, in that case constituting a circum- 
tonsillar abscess, or quinsy. The attempt has been made to classify 
inflammation of the tonsils on a bacteriological basis, but clinicallv 
we find so many varieties of microorganisms in healthy as well as 
in inflamed throats, some of them pathogenic and others non- 
pathogenic, that such a classification seems to be of little or no prac- 
tical value. There is an accumulation of evidence to show that the 
tonsils may be the avenues by which morbid germs enter the system 
and cases in which disease has affected the lungs, the pleura, the 
meninges and the joints through the tonsillar crypts seem to be 
fully established. 

Considerable discussion has taken place as to the infectiousness 
of simple inflammation of the tonsils, and while there seems to be 
some ground for accepting the theory of contagion it must be 
admitted that in nearly all cases a predisposition to the disease 
exists and that where epidemics occur the victims are exposed in 
general to similar atmospheric conditions. Moreover, it is a mat- 
ter of common observation that instead of being protected against 
succeeding attacks, as is true of contagious diseases, one who has 
suffered from tonsillitis is very liable to recurrence. 

A predisposing cause of tonsillitis is found in certain local mor- 
bid conditions such as affect lymphoid structures generally. Expos- 
ure to cold is recognized as an exciting cause, especially in indi- 

268 



ACUTE TONSILLITIS. 269 

viduals who have been overheated or are in a condition of depressed 
general health. There seems to be reason to believe that, in a large 
proportion of cases, the rheumatic diathesis prevails either in the 
individual or in the family and, from this standpoint, the theory of 
heredity gains some credence. In a certain number of cases errors 
in diet and functional irregularities in the female seem to induce an 
attack. In many no cause can be discovered. In acute cases it is 
usual to observe that the involvement of one tonsil is followed after 
a few days by that of the other. In some both tonsils may be 
affected at the same time and in all there is more or less simul- 
taneous congestion of the fauces and pharynx. 

We recognize acute and chronic forms of tonsillitis, and from a 
clinical and therapeutic standpoint it seems to be unnecessary to 
make any further discrimination. There is usually no difficulty in 
identifying an acute amygdalitis and in fact a diagnosis is generally 
made by the patient himself. The most conspicuous local symp- 
toms are more or less intense pain on swallowing accompanied by 
a sense of fulness and obstruction in the fauces. There is some 
sensitiveness on external pressure in the tonsillar region and indeed 
all the muscles of the neck may be quite stiff and painful. Pain 
may be felt in the ear of the affected side and almost constant tin- 
nitus aurium may be present. Constitutional disturbance is usually 
decided. . Headache, muscular pains, anorexia, chills and high tem- 
perature comprise a train of symptoms apparently out of proportion 
to a local disturbance of such simple character. On inspection of 
the affected parts the tonsils are seen to be red and turgid, and the 
palatal folds, the velum itself and the uvula may be swollen and 
edematous. If the crypts are involved their orifices are indicated 
by accumulations of yellowish-white secretion which may coalesce 
into a membranous formation resembling the exudate of diphtheria. 
If the cervical glands are swollen, which is not apt to be the case, 
except at a late period or in very intense forms of amygdalitis, the 
diagnosis may be quite dubious. The voice is thick and muffled, or 
may be husky from laryngeal congestion, and the relaxed condition 
of the vocal bands may require attention after the subsidence of the 
pharyngeal inflammation. The nasopharynx, the Eustachian tubes 
and the middle ear may become involved in an inflammatory proc- 



270 DISEASES OF THE NOSE AND THROAT. 

ess, especially in those who have had previous ear trouble or who 
are run down in health. 

In the chronic form of tonsillitis there may be little or no enlarge- 
ment of the gland but the lacunae which compose it are clogged 
with epithelial debris, decomposing secretions and bacteria which 
are a source of local irritation and may doubtless be a cause of a 
modified form of general septic infection. Such tonsils are prone 
to acute exacerbations when their volume may be temporarily very 
much increased. We are familiar with several varieties of reflex 
disturbance from these chronic inflammatory conditions referable to 
the acts of breathing and swallowing and, in some cases, the quality 
of the voice as well as its power may be distinctly impaired. The 
odor of the breath may be markedly offensive in cases of long stand- 
ing in which the secretions have been retained in the lacunae, and 
frequently little masses or balls of yellowish inspissated secretion 
may be extruded which emit a very foul odor on being crushed. 

In the treatment of acute tonsillitis the first thing to be done is 
to administer an active purge ; a saline laxative is the most satis- 
factory. If febrile reaction is prominent the internal use of drop 
doses of aconite every hour is efficacious. Quinine is very com- 
monly prescribed in this disease, especially when febrile reaction is 
marked, but probably without good reason, and, moreover, the detri- 
mental effect of this drug upon the ears, which in many of these 
cases are already to some extent impaired, should be remembered. 
Chlorate of potash in tablets containing five grains each, one to be 
dissolved in the mouth every two or three hours, seems to be sooth- 
ing in cases of mild type. A combination of chlorate of potash 
with tincture of the chloride of iron is believed by many to have a 
specific effect upon these septic processes, but there seems to be no 
valid foundation for this view, and certainly in my experience cases 
do equally well under doses less nauseous and less disturbing to the 
digestive track. 

Guaiac, in the form of lozenges, or as an ammoniated tincture, 
may be given every two or three hours until the bowels are acted 
upon. The salicylates, and more recently salol, have been used 
with satisfaction especially in cases in which the rheumatic diathesis 
is conspicuous. Some of the coaltar products, especially acetane- 



CHRONIC TONSILLITIS. 271 

lide and phenacetin, are popular, but should be used cautiously. 
During convalescence it is found necessary to resort to general 
tonics, since there often results a remarkable degree of systemic 
depression. 

Locally the use of sprays, inhalations and pigments is decidedly 
preferable to that of gargles. The act of gargling in acute inflam- 
mation is a source of irritation and any good accomplished must be 
thus more or less counterbalanced. The bicarbonate of soda in 
powder applied with a spatula sometimes gives marked relief. Ex- 
ternally water compresses or poultices of flaxseed may be a source 
of comfort. In the early stages of an acute inflammation of the 
tonsils the application of cold by means of Leiter's coil, or icebags, 
is serviceable. As a rule these cases are seen too late to be amen- 
able to cold applications and heat is found to be more grateful and 
effective. Friction of the neck with some stimulating embrocation 
is thought to do good by diverting the blood from the inflamed 
region to the surface. Swabbing the inflamed tonsil with pure tinc- 
ture of iodine is said by Floersheim to give prompt relief even when 
suppuration seems imminent, but his experience has not been fully 
corroborated. In fact in some cases a decided aggravation of the 
subjective symptoms has been noted. It is claimed that an attack 
may be aborted by painting the fauces with a strong silver nitrate 
solution (i dr. to I oz.). To most people this is an extremely dis- 
agreeable application and its value is doubtful. A mild solution is 
certainly irritating and useless, and the strong solution should be 
employed only in the early stages. Its mode of action is undeter- 
mined, whether as an antiseptic or by substituting a simple for an 
infective inflammation. In the experience of some attacks of fol- 
licular tonsillitis have been frequently aborted " by cleansing the 
tonsils with a saline solution, swabbing with peroxide of hydrogen, 
and then spraying with suprarenal, and repeating this treatment in 
twelve hours" (O. T. Osborne). A certain amount of suspicion 
always attaches to alleged " abortive " methods of treatment but 
that last mentioned has at least the negative advantage of being 
harmless. When several agents are used at the same time or suc- 
cessively it is rather difficult to decide which should receive credit 
for the effects observed. Pigments of menthol 3 twenty grains to the 



2J2 DISEASES OF THE NOSE AND THROAT. 

ounce of fluid albolene, applied at short intervals often give great 
relief. Tn the interval of the attacks any chronic morbid condition 
should be relieved or corrected as a prevention of recurrence. 

Chronically inflamed tonsils assume a great variety of shapes. 
Frequently portions of them may be so enlarged as to permit of 
partial excision. Many of them are tlat and so hidden behind the 
pillars as to be quite inaccessible. Others are riddled by distended 
crypts more or less filled with caseous material, a variety known as 
the " honey-combed " tonsil. When the tonsils are not enlarged 
the treatment consists in emptying the lacuna; by scooping out the 
caseous contents and then obliterating the diseased crypts by the use 
of some chemical caustic or the galvano-cautery. If the tonsil is 
enlarged the best treatment is removal with the guillotine or the 
wire snare, hot or cold, according to indications. In case radical 
interference be declined something may be done by applications of 
strong tincture of iodine, or by inserting into the crypts a probe 
charged with trichloracetic acid. Substantial results are obtained 
only by prolonged use of this method and with tonsils in which 
hyperplasia is not a prominent feature. In some of these cases 
habitual daily gargling with antiseptic solutions seems to be of bene- 
fit. It is claimed that the muscular exercise required by the act 
serves to empty the follicles clogged with detritus and is a healthy 
stimulant to the function of all the faucial region quite independently 
of any medicinal quality possessed by the fluid in use. By the ordi- 
nary mode of gargling only the anterior surfaces of the velum and 
tonsils and the dorsum of the tongue are reached. It is possible 
however for some individuals with a little practice to throw the fluid 
into the nasopharynx, or even the larynx, but the advantage of such 
a feat in pharyngeal gymnastics is doubtful. Laryngeal gargling 
is far from easy, but may be effected by the method of Guinier, 
described as follows. A small quantity of fluid is taken into the 
mouth, which is held open. The head must not be thrown back for 
fear of increasing the desire to swallow. While the lower jaw is 
protruded so as to draw forward the epiglottis the patient attempts 
to phonate any vowel sound, when the fluid at once finds its way into 
the larynx and bathes all the region above the vocal bands, provided 
the tendency to swallow, or to take an inspiration, can be resisted. 



DIPHTHERIA. 273 

The method of von Troeltsch, modified by Hagen, for gargling the 
pharynx is somewhat easier. The mouth being about half full of 
fluid is held open while a partial act of swallowing is attempted. 
This carries the fluid well into the pharynx where the expired air 
is made to gurgle through it in the usual way, as long as possible. 
When the process of exhalation is completed the tongue is placed 
firmly against the upper incisor teeth and by a quick forward jerk 
of the head the fluid is ejected, much of it passing into the naso- 
pharynx and out by the nostrils (H. L. Swain). Frequent repeti- 
tion of the attempts at swallowing while the mouth is open dilates 
the pharynx, relaxes the velum and thus favors the escape of the 
fluid by the nose, provided there is no nasal obstruction. The solu- 
tions used in this way should be saline, alkaline, or mildly astringent, 
and should be looked upon merely as adjuvants to other therapeutic 
measures and modes of local medication. 

A follicular tonsillitis in the acute stage is not to be regarded as a 
trivial matter. Cases in which septic absorption, followed by gland- 
ular suppuration, suppression of urine and other complications, has 
developed are well authenticated. Even in the absence of these 
disasters the affection is one calling for the most careful supervision, 
both on account of the immediate discomfort entailed and because 
of the subsequent systemic depression. 

DIPHTHERIA. 

It is not proposed to make an exhaustive review of the subject of 
diphtheria but it is important to be able to differentiate its local 
phenomena from those of other diseases which it resembles. 

The early diagnosis of diphtheria is often extremely difficult and 
there are forms of similar membranous inflammation that are con- 
fusing. A bacterial examination may settle the question but fre- 
quently there is neither time nor opportunity for this and we are 
obliged to rely upon clinical signs. The discovery of the Klebs- 
Loerfler bacillus in connection with a false membrane, may be con- 
sidered definitive, but its existence in the pharynx does not neces- 
sarily prove the presence of diphtheria. Many times the bacillus has 
been found in individuals in perfect health. There must be 3 there- 
18 



274 DISEASES OF THE NOSE AND THROAT. 

fore, a special susceptibility of the individual, or virulence of the 
poison, or possibly a still undiscovered toxin, to determine the actual 
development of the disease. In children the discovery of the bacil- 
lus, even in the absence of local symptoms other than slight sore 
throat, should put us on our guard. Such a case should be isolated 
until all doubt as to the character of the condition has been dissi- 
pated. It is necessary if possible, to make a complete examination 
of the suspected region ; small deposits of false membrane may exist 
at the root of the tongue, or behind one of the palatal folds, where 
they may be overlooked. 

A membrane so firmly attached that its removal causes bleeding is 
probably diphtheritic. Rapid extension of the deposit and invasion 
of the nasal chambers add to the gravity of the prognosis. Involve- 
ment of the larynx, especially in children, is a very serious phe- 
nomenon. Sudden fall of temperature is indicative of collapse 
while a rapid rise means septic absorption. A rapid pulse is not 
necessarily a bad sign but irregularity and weakness are unfavor- 
able. Albuminuria occurs in a large proportion of cases but be- 
comes serious only when complicated by suppression of urine and 
other signs of severe kidney lesion. In diphtheria the systemic 
depression is out of proportion to the local phenomena. In other 
words we have to deal with a constitutional disease of which the 
symptoms presented on the mucous membrane are a local expres- 
sion. In an average case the membranous exudate seems not merely 
upon the surface but to be incorporated in the substance of the 
mucosa. The attendant hyperemia differs from that of an acute 
inflammation in being more livid in hue, and the subjective symp- 
toms are distinctly less intense. A non-diphtheritic pseudomembrane 
may be readily removed and its careful detachment is not apt to 
leave a bleeding surface. The color of a diphtheritic membrane is 
usually yellowish white at first, but it soon becomes blackened by 
admixture with blood and necrotic tissue. At the same time a 
decided fetor of the breath may be detected and the cervical glands 
may be swollen and sensitive. A croupous membrane is thin, glazed 
and white, does not become discolored and is easily detached. In 
follicular tonsillitis the exudate is discrete and indicates the mouths 
of lacunae, or if it becomes confluent does not extend beyond the 
surface of the tonsil. 



DIPHTHERIA. 



275 



There is reason to believe that not every membranous deposit in 
the upper air track is due to the Klebs-Loeffler bacillus, while on 
the other hand certain non-membranous inflammations owe their 
origin to this organism. True diphtheria is caused by a specific 
bacillus or its toxins, but there are many microscopic organisms 
similar in character which are strictly non-pathogenic. The mor- 
phological features of the diphtheria bacillus are not reliably dis- 
tinctive. The chemical test sometimes employed is not absolute, 
owing to varying degree of acid-producing power in different bacilli. 
Animal inoculation may furnish satisfactory evidence, provided we 
can exclude the possibility that certain non-diphtheritic bacteria are 
fatal to lower animals. Moreover, pathogenic bacilli may lose their 
virulence in artificial cultures and hence fail to produce an effect. 
Immunization of a control animal with diphtheria antitoxin might 
be conclusive, but this takes time, a point of vital importance in 
diphtheria. Nearly every practitioner has had fatal cases, in which 
the bacteriological testimony was negative, and on the other hand 
has been compelled to keep a suspected patient in quarantine for 
weeks solely on microscopic evidence. Hence we are forced to 
reach a diagnosis mainly from the clinical history and local appear- 
ances, looking to bacteriology only for the somewhat uncertain con- 
firmation it is authorized to give. 

The following points in tabular form may be serviceable. 

Tonsillitis. D ip h theria . 

Begins abruptly, with chill, rapid Comes on gradually, usually 

rise of temperature — 104 de- without chill, 

grees or more — headache, Moderate rise of temperature, 

muscular pains and general vomiting and albuminous 

malaise. urine. 

Tonsils swollen and covered by Tonsils not especially large un- 

an exudate in the form of less previously hypertrophied, 

a non-adherent pseudomelia- but more or less covered by 

brane, or more often the thick adherent membrane, 
mouth of each separate follicle 

is clogged with yellowish Cervical glands apt to be swol- 

white secretion. Icn and sensitive. 



276 DISEASES OF THE NOSE AND THROAT. 

Tonsillitis. Diphtheria. 

Spots or patches of membrane Membrane removed with diffi- 

easily brushed off without culty and exposed surface 

causing bleeding and seldom bleeds. Returns in a few 

reform. hours. 

Exudate is limited to the follicles Membrane may be found almost 

or surface of the tonsil and anywhere on the mucous sur- 

the mucous membrane is uni- face which is not intensely red, 

formly red. but is usually dark red or livid 

around the membranous de- 
posit. 

The bacilli of a simple inflam- Pathognomonic Klebs - Loeffler 

matory process are present. bacilli usually found. 



CIRCUMTONSILLAR ABSCESS; OR QUINSY. 

Circumtonsillar abscess, or quinsy, is an acute inflammation of the 
tissues contiguous to the faucial tonsil as well as of the gland itself 
resulting in the formation of pus. In a large proportion of cases 
the focus of suppuration is located immediately at the upper border 
of the tonsil and involves the soft palate. In rare instances it occurs 
behind the tonsil simulating retro-pharyngeal abscess ; and, still less 
frequently, the pus may be incarcerated underneath the tonsil which 
may be pushed into the faucial space without being itself especially 
affected. Abscess of the tonsil proper is a rare occurrence, but when 
pus is formed in the situation last referred to it is not unusual for it 
to escape through one of the tonsillar crypts. 

The valuable researches of J. L. Goodale show some interesting 
facts regarding tonsillar, or intrafollicular abscesses. In most cases 
the intratonsillar process was found alone, in a few it was accom- 
panied by circumtonsillar inflammation. There seem to be no clin- 
ical signs which define an abscess in a follicle, except that a severe 
grade of infection is indicated by a more profound constitutional 
disturbance than is met with in a simple proliferative amygdalitis. 
Suppurative foci are often found to be numerous, and in such case 
the streptococcus pyogenes was observed to be more abundant than 
forms of staphylococcus, the crypts contained a large amount of 



CIRCUMTONSILLAR ABSCESS : QUINSY. 277 

fibrinous exudate, and in several instances pus had burrowed into 
an adjoining crypt. In cases accompanied by circumtonsillar in- 
flammation the interfollicular lymph channels and the connective 
tissue lymph spaces near the base of the tonsil were crowded with 
polynuclear neutrophiles, in one case seen to extend directly from 
an abscess within toward the base of the tonsil. It is surmised, 
although the evidence may not yet be thought complete, that an 
intrafollicular abscess is a sequel of primary infection of a crypt by 
the streptococcus pyogenes and is not of embolic origin, and that 
circumtonsillar inflammation may be due to discharge of a tonsillar 
abscess into the efferent lymph channels. 

Quinsy is a rare disease in childhood and the tendency to it dis- 
appears with advancing years. In exceptional cases a first attack 
occurs in late adult life. In children the natural objection to an 
examination makes it far from easy to reach a diagnosis. Fixation 
of the lower jaw, always symptomatic, adds to the difficulty. If 
the finger can be inserted into the mouth a unilateral sometimes fluc- 
tuating tumor may be detected. The necessity of protecting the 
examining finger, or using a mouth-gag, is especially important. 
Pain and often torticollis together with marked constitutional dis- 
turbance are present. The danger from edema, or spontaneous rup- 
ture of the abscess in a child is far greater than in an adult. 

The causes of quinsy are not always evident. Exposure to cold 
is a recognized exciting cause and seasonal influences are very 
marked, cases being much more frequent during the spring and fall 
months than at other periods of the year. It seems to be an hered- 
itary disease, or at least many cases occur in the same family. It is 
sometimes possible to get a distinct history of rheumatism in the 
individual or in the family ; although it is perhaps less frequently 
the case in this than in other forms of amygdalitis. Previous en- 
largement of the tonsil would seem to provide a tendency to inflam- 
mation, although cases are often observed in which the tonsillar 
tissue itself seems to be but little, if at all, hypertrophied. 

Many cases begin as a simple acute lacunar amygdalitis. An 
attack of quinsy is usually announced by a chill or at least by chilly 
sensations. There are more or less pyrexia and systemic disturbance, 
muscular pains, headache and general malaise. A feeling of discom- 



2/6 DISEASES OF THE XOSE AND THROAT. 

fort in the fauces soon develops into actual pain aggravated by swal- 
lowing, and the pain may shoot up toward the ear of the affected 
side and assume a lancinating character. As a rule, in twenty-four 
to forty-eight hours distinct tumefaction appears in the classical sit- 
uation at the upper border of the tonsil between the palatal folds. 
There may be more or less edema of the velum and uvula and the 
function of the velum may be so impaired as to cause regurgitation 
of fluids into the nose on attempts at swallowing. The voice is 
characteristically altered and muffled, the patient is annoyed by 
accumulation of thick, tenacious mucus in the fauces, the attempts 
to clear the passages by hawking being exceedingly painful. The 
salivary secretion is markedly increased and inability to dispose of 
it adds to the patient's discomfort. Fortunately the affection is 
usually limited to one side although there may be consecutive inflam- 
mation involving the second tonsil. If allowed to pursue its course 
spontaneous rupture of the abscess may take place either through 
the anterior pillar or between the pillars at the upper border of the 
tonsil. 

From the symptoms that have been detailed there should be no 
question in making the diagnosis of quinsy. In some instances 
digital examination gives a positive sense of fluctuation but it is 
not always to be relied upon since the pus may be so deeply seated 
as to fail to give the characteristic sensation on palpation. 

Cases are on record in which quinsy has been mistaken for other 
lesions ; among them, aneurism, malignant disease, diphtheria and 
syphilis ; but, after a careful study, such mistakes seem hardly pos- 
sible. In a case of aneurism, supposed to be quinsy, a bistoury was 
plunged into the tumor with the result of producing hemorrhage 
which was controlled only by ligation of the carotid artery. In this 
case palpation had previously detected pulsation which should have 
been accepted as a warning. In malignant disease there is usually 
more or less of an ulcerative process which does not occur in quinsy ; 
while the rapid development of peritonsillar inflammation would tend 
to exclude malignancy. With diphtheria there is probably more 
danger of confusion, at least in the early stages ; but enlarged cer- 
vical glands, albuminuria and the presence of bacilli in the exudate, 
together with the absence of very marked or intense local symptoms 



CIRCUMTONSTLLAR ABSCESS : QUINSY. 279 

would establish a diagnosis of diphtheria. A syphilitic gumma of 
the tonsil or in its neighborhood might, when inflamed, resemble 
quinsy, but it is rare to have acute symptoms in connection with a 
gummatous process and, in the majority of cases, we discover other 
manifestations of syphilitic infection. 

As a rule, the pus formed in the course of quinsy, succeeds in find- 
ing an outlet, the patient obtains relief from painful symptoms by 
rupture or puncture of the abscess and recovery ensues. The prog- 
nosis, under most circumstances, is good. In some cases, the proc- 
ess of suppuration may be slow, the tissues enclosing the pus may 
be so brawny and tough as to yield slowly to the pointing of the 
abscess. The condition may be practically converted into one of 
chronic abscess of the tonsil. In other cases, when the patient is 
very reduced in strength or advanced in years, there may be danger 
from the escape of pus into the air-passages and the occurrence of 
asphyxia, or the pus may find its way into the mediastinum by way 
of the pharyngomaxillary fossa. A fatal result may follow from 
absorption of pus and the formation of metastatic abscesses, thrombi, 
etc. Such occurrences are extremely rare. The pus may bore its 
way through the wall of a neighboring blood-vessel and lead to the 
occurrence of hemorrhage. Happily, the large blood-vessels in the 
vicinity are protected by a considerable amount of connective tissue 
and they are not easily reached, although a number of cases in which 
the internal carotid artery has been invaded are on record, all ter- 
minating fatally. 

An interesting contribution to the subject of hemorrhge from a 
circumtonsillar abscess has recently been made by W. F. Chappell. 
In a case which he reports an abscess was opened by a small incision 
in the usual situation, and four days later a hemorrhage of about six 
ounces occurred and was repeated in still larger amount in four 
hours. It was controlled by astringent applications, but five days 
afterward a third bleeding to about eight ounces was followed by 
persistent oozing. The abscess cavity distended with clots was then 
freely opened and packed with iodoform gauze after having been 
irrigated with hydrogen peroxide. Under daily renewal of this 
dressing the cavity healed and no more bleeding took place. After 
the second hemorrhage an examination of the urine showed albu- 



280 DISEASES OF THE NOSE AND THROAT. 

minuria with epithelial and pus cells and granular casts. During 
convalescence a severe attack of rheumatism involving' the muscles 
of the calves and to some extent certain joints occurred, and the 
opinion is expressed that this as well as the nephritis must be attrib- 
uted to the tonsillar abscess. In a search of the literature of the 
subject this observer finds several interesting similar cases and a 
surprising mortality. In most of them the internal carotid appears 
to have been opened by ulceration, in one the lingual artery (Thomas 
Watson), and in one the blood seemed to come from " rupture of a 
small abscess on the posterior surface of the velum " (Brewer). In 
Chappell's case the ascending pharyngeal artery, seen at the posterior 
wall of the cavity, was suspected. In some of the cases referred 
to the abscess was incised, but in most of them spontaneous rupture 
took place, a fact which suggests the importance of early opening 
of a circumtonsillar abscess. In the event of hemorrhage there can 
be no doubt that exposure and firm packing of the abscess cavity 
should be practised before resort is had to ligation of the carotid, 
the latter expedient having been used successfully in two of the cases 
noted. 

The treatment of quinsy consists, in the early stage, in an attempt 
to abort the disease and prevent the formation of pus. Unless seen 
early it is impossible to accomplish this. Revulsives in the shape 
of hot foot baths, diaphoretics and an active purge will sometimes 
succeed, in conjunction with the internal use of a very old fashioned 
but excellent remedy, guaiac. On the rheumatic theory in recent 
years salicylates have supplanted the older drug but are little, if at 
all, more effective and are probably less safe. The alkaline treat- 
ment with bicarbonate of soda recommended many years ago has also 
given good results. It is used internally, as well as locally. The 
tincture of aconite, recommended by Ringer, is also of use. When 
the symptoms are very acute gargles are a source of so much pain 
that they are not only ineffectual but the muscular effort required 
seems to aggravate the local disturbance and so counteract, in a 
measure, any good effect they may have. The objection does not 
apply to the use of sprays or pigments, some of which are found 
to be efficacious. One of the best applications in any form of inflam- 
mation of the tonsils is a combination of the three sodas, the bicar- 



TREATMENT OF QUINSY. 281 

bonate, biborate and salicylate, of each equal parts, a teaspoonful of 
the mixture being dissolved in about four ounces of hot water and 
sprayed into the throat or, if preferred and the parts be not too sen- 
sitive, the solution may be used as a gargle. At the same time the 
salicylate of soda may be given internally in doses of ten grains 
every two hours until its physiological effects are obtained. Am- 
moniated tincture of guaiac may be used as a gargle by adding a 
tablespoonful to a glass of hot milk, a mouthful of the mixture being 
swallowed every hour until the bowels are acted upon. In the early 
stages external applications of dry cold in the form of ice-bags are 
sometimes of service. 

When the foregoing measures appear to have failed and signs of 
suppuration are distinguished, the only resort is to surgical meas- 
ures. If the pus points at the upper border of the tonsil an incision 
should be made through the anterior pillar with a sharp-pointed bis- 
toury, the blade of the knife being held parallel to the fibers of the 
palato-glossus muscle and directed obliquely upwards and inwards. 
A small cataract knife will be found a very convenient instrument 
since its triangular blade makes a large vent for the escape of pus 
and the thinness of the blade facilitates its introduction. When the 
knife is passed in the situation described there is no risk of striking 
any important blood-vessels except, of course, in the existence of 
some abnormality. Usually pus begins to escape before the knife can 
be withdrawn and the relief to the patient is immediate. The prelim- 
inary application of cocaine does very little good in the way of dead- 
ening the pain of the cut which is, of course, considerable but mo- 
mentary. The pus may be so deep seated as not to be reached by 
an incision which may be considered safe; in such case the insertion 
of a blunt probe into the cut may succeed in opening the abscess 
wall and, even if pus does not escape, the incision relieves tension 
and encourages its progress towards the surface. Sometimes the 
wall of a deep-seated abscess may be ruptured by plunging an ordi- 
nal')- polypus forceps into the wound and forcibly separating its 
blades. 

In some cases of tonsillar abscess in which an accumulation of pus 
exists at the bottom of a crypt or in wbich the focus of suppuration 
is just outside the tonsillar capsule, a method of treatment recently 



252 DISEASES OF THE NOSE AND THROAT. 

revived by ( i. A. Leland will be found efficacious although somewhat 
heroic. A vertical incision of considerable extent is made in the 
tonsil itself with an angular tonsil bistoury and then the finger is 
introduced into the wound and the tissues broken down by a grad- 
ual tearing process. Local anesthesia is usually sufficient. Some- 
times a dense-walled cavity is opened in which is found a quantity 
of pus. Reaction is seldom excessive and the relief of symptoms 
is generally immediate. In these cases it is supposed that the trouble 
begins in a tonsillar crypt, thence extending to the circumtonsillar 
tissue. Breaking down the tissues, as suggested by Hoffmann, and 
called by him " discission," may be effected by means of a large stiff 
probe, but the forefinger answers better. 

When pus is not disclosed by scarification the process of suppura- 
tion should be promoted by hot applications externally and by means 
of hot inhalations and gargles. The external application most grate- 
ful and effective is a hot flaxseed poultice which should be large 
enough to cover the whole side of the neck and should be overlaid 
by a piece of oiled silk. When pus evacuates itself, or is released 
by incision, the inflammatory process promptly subsides and prac- 
tically the attack is over. But the tendency to the disease may still 
remain and if predisposing causes such as enlarged tonsils can be 
recognized they should be removed. It is not safe, however, to 
guarantee a patient against recurrence of quinsy after partial excision 
of the tonsils, since it not infrequently happens that an attack will 
take place within a few months after a tonsillotomy. Hence the 
necessity of a " tonsillectomy " rather than a tonsillotomy. The 
importance of extirpating the upper part of the tonsil as a preventive 
of peritonsillar phlegmon has recently been insisted upon by Ricardo 
Botey. The gland is often deeply seated in the angle between the 
pillars to which it may be firmly adherent. The ordinary methods 
of excision do not reach it and it must be enucleated by a careful 
dissection. Attention to the mode of life and the habits in general, 
and the correction of a rheumatic tendency will do more to banish 
a predisposition than local treatment alone. An attack of quinsy is 
almost always brought on by overexertion and is favored by a state 
of low vitality. Recovery is apt to be tedious and needs to be 
assisted by tonics and generous diet. 



VINCENT'S ANGINA. 283 

ULCERO-MEMBRANOUS OR DIPHTHEROID ANGINA. 

It must have fallen to the lot of every practitioner of wide expe- 
rience to be puzzled by a form of sore throat resembling diphtheria 
but free from violent constitutional disturbance. In these cases a 
true ulcerative process goes on involving a very limited area or the 
entire surface of the tonsil, extending through the whole thickness 
of the gland or affecting only its superficial portion. The mildness 
of the associated systemic disturbance differentiates it from a con- 
fluent follicular amygdalitis. Usually but one tonsil is involved and 
adjacent parts are not extensively invaded. The submaxillary 
glands of the corresponding side are generally enlarged and remain 
hard some time after the throat symptoms disappear. The gross 
appearance of the membrane suggests diphtheria, but no Klebs- 
Loeffler bacilli and indeed few microorganisms of any kind are to 
be found, except the fusiform bacillus of Vincent, which is uni- 
formly present in large numbers and is thought to be the special 
microbe of the disease. Both a bacillus and a spirillum are present, 
the former being fusiform in shape and straight or curved and stain- 
ing promptly with aniline fluids. The fusiform bacillus is found 
normally in the mouth and has been discovered in pus from the an- 
trum and in that of a perilaryngeal abscess ; it has not been cultivated 
in artificial media and has not been proved to be pathogenic to ani- 
mals. Although this seems to be a comparatively mild disease, 
Watson Williams asserts that it is very fatal in children. Usually 
the membrane clears off in a week or two and the parts resume their 
former appearance except so far as tissue may have been destroyed 
by ulceration, and even then the resulting deformity is far from 
commensurate with the loss of tissue. In a recent case in my clinic 
an ulcer occupied the left tonsil and the mucous membrane near the 
last molar teeth. Tt was irregular in contour, quite deep and sloughy 
in appearance, and was extremely sensitive. The cervical glands 
were implicated and were very hard and tender. Although there 
was no history of syphilis, the young man was put on mixed treat- 
ment and in the meantime a smear from the surface of the ulcer 
was examined under the microscope. The specimen was found to 
be crowded with fusiform bacilli and spirilla. Internal treatment 



284 DISEASES OF THE NOSE AND THROAT. 

was stopped and the nicer was simply bathed at short intervals with 
hydrogen peroxide. Repair began at once and rapidly progressed. 
Notwithstanding the apparent depth of the nicer, the parts have 
healed with hardly a trace of damage. The average case is much 
more likely to be confounded with follicular tonsillitis or diphtheria, 
especially the latter. Severe constitutional disturbance and clogging 
of the tonsillar lacunae with inflammatory products characterize the 
former, while diphtheria is not an ulcerative disease, except occa- 
sionally in the third or fourth week, by which time its nature is usu- 
ally demonstrated by profound systemic depression. The micro- 
scopic testimony is conclusive. Although the proof is not yet abso- 
lute, this lesion is probably caused by a specific organism for reasons 
expressed by Sobel and Herrman, in a very complete review of the 
subject, as follows: the presence of fusiform bacilli in large num- 
bers, their rapid disappearance as the ulceration heals, the scarcity 
of other microorganisms and the occasional transmission of the dis- 
ease from one individual to another. The duration of the affection 
is usually less than three weeks, and may be reduced by appropriate 
treatment. One case (Lemoine) lasted seventy days. 

The local treatment which has been found most effective has been 
the application of iodine in some form, preferably Lugol's solution. 
Nitrate of silver, in three to five per cent, solution, and ten per cent, 
chromic acid have also proved serviceable, and recently Siredey has 
recommended pure methylene blue in powder rubbed well into the 
lesions. 



i 



CHAPTER XVI. 

BENIGN NEOPLASMS OF THE TONSIL. TONSILLITHS. MALIGNANT 

DISEASE OF THE TONSILS. TUBERCULOSIS, LUPUS AND SYPHILIS 

OF THE PHARYNX. NEUROSES OF THE PHARYNX. FOREIGN 

BODIES IN THE PHARYNX. 

Benign neoplasms of the tonsil comprise lymphoma, fibroma, 
papilloma, angioma and lipoma. The first is rarely seen except in 
combination with other neoplasms, especially sarcoma. In its simple 
form it is a lymphoid hyperplasia and may be a local manifestation 
of a diathesis. 

Fibromata are met with in the tonsil either as sessile tumors, or 
infiltrations, so to speak, or more commonly, as small pedunculated 
tumors springing from the mucous lining of a crypt. 

Papillomata are very commonly seen on the velum and uvula and 
less frequently on the surface of the tonsil, invariably pedunculated 
and resembling the adjacent mucous membrane in color. 

Angiomata are rare except in combination with, or secondary to, 
other neoplasms. One or two examples of lipoma are on record. 

Tonsilliths, or tonsillar concretions, are now and then met with in 
a distended tonsillar crypt where they may give rise to very little 
reaction, or are productive of symptoms which might be expected 
from a foreign body. Not infrequently they are discovered in an 
attempt to excise an apparently enlarged tonsil. These concretions 
are composed mainly of calcareous material, phosphate and carbon- 
ate of lime and epithelial debris, frequently with a parasitic nucleus, 
the leptotJirix buccalis. 

The treatment of a tonsillar calculus consists in its removal fol- 
lowed by thorough curetting of its bed, with excision of redundant 
portions of tonsillar tissue. Small concretions in the lacunae are not 
very uncommon. The largest tonsillith on record weighed 26.8 
grammes (Robertson). It was somewhat egg-shaped, and the most 
remarkable thing about it was that, in spite of its enormous size, its 
existence was not suspected until its expulsion during a violent 

285 



286 DISEASES OF THE NOSE AND THROAT. 

paroxysm of coughing. A deep excavation in the tonsil marked its 
site. 

Malignant disease of the tonsil occurs under two forms, epitheli- 
oma and sarcoma. Either of these may be primary in the tonsil, or 
may reach that organ by extension from the tongue or from the 
pharynx. We find several subvarieties of these two forms, the most 
common being the round-celled sarcoma ; next the squamous epithe- 
lioma and finally lympho-sarcoma. Others are practically clinical 
curiosities. 

In the early stages of sarcoma there is a decided tendency to 
limitation of the disease by a definite line of demarcation from the 
healthy tissue, or even encapsulation, ulceration being a late phe- 
nomenon. In epithelioma, ulceration is an early occurrence and the 
lymph glands are usually involved at an early stage. As with these 
growths in other situations we find sarcoma in the young as well as 
the old, while epithelioma is met with at, or after, middle life. In 
many cases no cause is discoverable while in others a distinct source 
of irritation, either in occupation or habits, may be ascribed as a 
cause. Syphilis may be admitted as an etiological factor while the 
influence of heredity is accepted by many observers. 

The pain in malignant disease, if not more severe, is more lasting 
than that of any other form of tonsillar disease and, in many cases, 
it is intense and extends to the ear of the side affected. Impediment 
to phonation and deglutition is dependent upon the dimensions of 
the tumor, or the degree of ulceration. The color of a sarcoma is 
generally paler than that of adjacent parts and until ulceration takes 
place the tumor may be quite symmetrical in its contour. 

An epithelioma is usually warty and irregular. Frequently the 
excrescences which compose it are quite pallid. After the estab- 
lishment of ulceration a thin and very offensive secretion is formed 
and there is a constant desire to clear the fauces. The appearance 
of cachexia is earlier and more pronounced in epithelioma than in 
sarcoma. Not uncommonly a syphilitic taint may complicate the 
cancerous lesion of the tonsil and, in many cases, it becomes neces- 
sary to differentiate the two diseases. In syphilis swallowing may 
be difficult and somewhat painful. In cancer there is marked odyn- 
phagia and spontaneous acute pain is almost continual. Syphilitic 



CANCER OF THE TONSIL. 287 

lesions of the tonsil are usually either superficial in the form of 
mucous patches, or occur later as deep destructive ulcerations, some- 
what resembling cancer. A gummatous infiltration of the tonsil 
before the stage of softening looks more like sarcoma. In cancer 
there is always a neoplasm which ultimately breaks down. In 
syphilis there may be a moderate amount of lymphadenitis which on 
examination is found to be general. In cancer only the neighboring 
lymphatic glands are indurated and they are painful, or sensitive. 
Hemorrhage in syphilis is rare while in cancer it may be frequent 
and free. The absence of cachexia in the former and its presence 
in malignant disease at an early stage may usually be determined. 
A microscopic examination will usually settle any question as regards 
epithelioma, but in sarcoma is somewhat less conclusive. In many 
cases the early symptoms simulate so closely those of simple hyper- 
trophy of the tonsil that amygdalotomy may be proposed and in 
several instances it has actually been done under this misapprehen- 
sion. Such an error may be excusable, but is not likely to occur if 
a digital examination discloses an unusual degree of induration. 
Moreover, unilateral enlargement of the tonsil should always suggest 
the possibility of syphilis, or a neoplasm. A tentative course of 
iodide of potash may assist in removing doubt as to syphilis. A 
most interesting case of tonsillar tumor first reported by Bryson 
Delavan as a tertiary ulceration simulating sarcoma illustrates how 
the microscope at times fails to clear up a doubtful clinical diagnosis. 
After two months of soreness and swelling of the tonsil a deep ulcer 
with sloughy base and everted edges formed, the body of the gland 
being indurated. There was some pain on swallowing and the cer- 
vical glands were slightly enlarged. The mass was removed with 
the cold-wire snare and sections were examined by several patholo- 
gists, some of whom pronounced it sarcoma while others were in 
doubt. The slow development of the tumor and the presence in the 
microscopic sections of an extraordinary number of endothelial cells 
led to the adoption of a diagnosis of syphilis. Iodide of potash was 
given continuously. One year later the tumor was as large as ever, 
was quite hard, and was adherent to the pillars of the fauces without 
infiltrating adjacent tissue. It was somewhat nodular but was not 
ulcerated. A few of the cervical glands were indurated. The neo- 



288 DISEASES OF THE NOSE AND THROAT. 

plasm was dissected out under ether by R. P. Lincoln, who placed 
sections in the hands of several experts. They agreed in excluding 
malignant disease, but were divided between syphilis and simple in- 
flammatory hyperplasia. Eighteen months later there had been no 
recurrence. 

In several cases noted by Newman and others malignant degenera- 
tion of an old syphilitic gumma has been observed. 

The prognosis in malignant disease is, of course, extremely un- 
favorable. 

In the early stages the disease may be retarded by removal of the 
primary lesion together with the affected glands, but surgery affords 
little hope as regards complete eradication of the disease. Early 
external operation has been resorted to in many cases but final results 
have been as a rule far from encouraging. It is hardly ever possible 
to reach the disease through the mouth. Extensive incisions in the 
neck with division of the upper jaw for exposure and extirpation 
of infiltrated glands, as well as of the primary lesion, are required. 
A preliminary tracheotomy is not essential. A radical operation of 
this kind may be justifiable with a view to prolonging life and in the 
hope that recurrence which is inevitable may take place in a region 
where less suffering may be imposed upon the patient. The round- 
celled sarcoma, or lymphosarcoma is especially virulent and accord- 
ing to David Newman " it is a malady in which, even from ths 
onset, little hope can be entertained of saving the patient." Early 
operation in epithelioma gives a somewhat better chance, but the 
chief difficulty, as pointed out by Butlin, lies in the intimate relation 
between the pharyngeal structures and the cervical lymphatics, so 
that dissemination of the disease takes place promptly. Yet in sev- 
eral cases of the spindle-celled variety of sarcoma the tumor was 
found to be enclosed by a capsule from which it was actually shelled 
out. Electrolysis or cataphoresis, or the injection of toxins after 
the method recommended by W. B. Coley may be tried and they 
seem to offer some hope of success, at least in sarcoma. In the 
majoritv of cases we are dependent wholly upon palliatives for the 
relief of pain. The application of cocaine to the diseased or ulcer- 
ated surface, insufflation of orthoform, and the hypodermic injec- 
tion of morphine give temporary amelioration. 



TUBERCULOSIS OF THE PHARYNX. 289 

TUBERCULOSIS OF THE PHARYNX. 

In spite of the fact that the bacillus is supposed to be capable of 
entering the system through intact epithelium and that it is fre- 
quently found in the air tract of perfectly healthy people, authentic 
cases of tuberculosis affecting the structures of the pharynx are very 
few. As a rule, in this situation it is secondary to pulmonary dis- 
ease or coincident with it ; or, it may occur as a sequel to tubercular 
disease of the cervical vertebrae. Primary cases have been reported 
but there is always a suspicion that a deep-seated or limited lesion 
in the lung may have escaped detection. In a case of my own a 
deep ulcer involving the right side of the base of the tongue was 
diagnosed as carcinoma and the whole tongue was excised. There 
were no signs of pulmonary disease at the time and none appeared 
subsequently. 

The diagnosis is often difficult either because of the absence of 
significant appearances in the lesion itself or because of the existence 
of a mixed infection, the condition being masked by certain phenom- 
ena due to syphilis. In a typical case of disseminated miliary tuber- 
culosis the character of the lesion may be sufficiently clear; the 
nibbled, worm-eaten appearance permits of little chance of confusion 
with the deep ulceration of syphilis. Moreover, a bacterial exam- 
ination will generally discover the bacillus. The tubercular deposit 
may involve the tonsil, the velum, or any part of the pharyngeal wall. 
Associated with the local lesion we usually find more or less pro- 
nounced cervical lymphadenitis. 

The early symptoms are those of subacute inflammation and their 
real character may not be suspected in the absence of physical signs 
in the lung. At the outset considerable swelling is observed, fol- 
lowed by the formation of yellowish spots of miliary tubercle which, 
after a time, may soften and form small ulcers, usually round and 
superficial, covered by a grayish secretion and surrounded by pale 
mucous membrane. Thus several independent foci of ulceration may 
develop giving the tissues a so-called worm-eaten appearance. Indi- 
cations of an attempt at spontaneous repair may be observed at some 
points but the cicatrices are prone to break down. 

Pain is generally pronounced and aggravated by swallowing until 
19 



29O DISEASES OF THE NOSE AND THROAT. 

deglutition may become impossible, or the patient may complain 
merely of sensations of dryness and heat. The voice is affected 
either by more or less involvement of the larynx or bv accumulation 
of secretion the expulsion of which the patient dreads to attempt. 
The breath is fetid. There may be a dry cough or expectoration 
may be free if the lungs are involved. The usual general symptoms 
of tuberculosis sooner or later present themselves. In addition, the 
presence of bacilli in the scrapings from the ulcer may establish the 
diagnosis. 

The prognosis is necessarily bad both because a lesion in this sit- 
uation must be considered indicative of a severe type of disease and 
because of the interference with nutrition owing to dysphagia. 

The treatment is that of general tuberculosis and, in addition, 
certain local applications may give good results in primary cases and 
in those not complicated by extensive pulmonary or laryngeal disease. 
In any case we are called upon to adopt measures for the relief of 
pain. An ulcerative process favorably located may be treated by 
curetting and lactic acid, followed by insufflation of iodoform and 
orthoform which together seem to produce anesthesia and promote 
cicatrization. The use of pineapple juice as a spray or a gargle is 
recommended by some as a detergent and mild astringent as well as 
for the relief of pain. Spraying with a solution of suprarenal cap- 
sule seems to be somewhat effective in the mitigation of irritability, 
and in extreme cases the local use of cocaine and of morphine inter- 
nally may be required. Suitable climatic conditions and the usual 
constitutional remedies are indicated. 

Odynphagia in this disease as well as in some cases of tuberculo- 
sis of the larynx often demands first attention. The pain in swal- 
lowing may be so extreme that the patient finally gives up attempt- 
ing to eat. The natural result is a rapid decline in strength and 
vitality. In the majority of these cases nothing has been found to 
equal orthoform as a local sedative. Cocaine enables the patient to 
swallow with comparative comfort but is often objectionable on 
account of the paresthesia it excites. A most excellent mode of 
administration is in the form of a lozengs containing one quarter of 
a grain of orthoform, one or two to be dissolved in the mouth ten 
or fifteen minutes before food is taken. Thus we are enabled to 



LUPUS OF THE PHARYNX. 20,1 

employ one of our most valuable resources, namely hypernutrition, in 
combating the inroads of tuberculosis. 



LUPUS OF THE PHARYNX. 

Lupus of the. pharynx in some respects resembles tuberculosis, but 
exhibits several important points of distinction. The pain and con- 
stitutional disturbance met with in the latter are quite absent. The 
evidence that lupus is a modified form of tuberculosis and that most 
patients affected with the former die of tuberculosis does not seem 
to be wholly sufficient. Moreover, the presence of tubercle bacilli in 
a lupoid lesion has not yet been clearly demonstrated. It is very 
slowly progressive and is not attended by severe subj-ective symp- 
toms. The function of the pharyngeal structures may be interfered 
with if the velum or the epiglottis are involved owing to thickening 
from infiltration, destructive ulceration, or cicatricial bands. The 
affected region presents a granular appearance in the shape of small 
nodules, soft, insensitive, non-vascular, and in color differing but 
slightly from the surrounding mucous membrane. There may be 
considerable destruction of tissue and the resulting deformity from 
cicatrization, if repair takes place, may be very marked. 

In many cases the process is mistaken for syphilis but the history 
of the case, the superficial character of the ulceration and its rapid 
cicatrization independent of special treatment, should establish the 
diagnosis. Glandular involvement is rather rare in lupus, whereas 
a general lymphadenitis is almost invariable in syphilis. Tentative 
treatment may be misleading for the reason that strumous condi- 
tions, under which lupus is sometimes classed, are often benefited 
by alterative medication, while some cases of syphilis offer obstinate 
resistance to specific remedies. 

The majority of cases terminate fatally, but some cures are re- 
corded as a result of thorough ablation of diseased tissue and cauteri- 
zation. Tonics and careful nutrition are no less important. 

In a case under my observation man)' years ago in the service of 
Dr. Asch at the New York Eye and Ear Infirmary, the disease in- 
volved the entire velum and thence extended to the larynx. It grad- 
ually yielded with moderate deformity under persistent applications 



292 DISEASES OF THE NOSE AXD THROAT. 

of saturated solution of silver nitrate and Fowler's solution inter- 
nally, and later perchloride of iron locally, two drachms to the ounce, 
combined with the internal use of iron and cod-liver oil. In this 
case the duration of the disease, from the beginning of treatment to 
the time when a cure was pronounced, was upwards of two years. 

SYPHILIS OF THE PHARYNX. 

Manifestations of syphilis are met with in the pharynx at any 
stage of the disease, either independently or coincident with cuta- 
neous eruption. 

The primary sore, or hard chancre, has been observed many times 
upon the tonsil and sometimes presents appearances which permit of 
its easy recognition. The first symptom is a sore throat, aggravated 
by pain in swallowing, which does not yield to ordinary treatment. 
The affected tonsil may be considerably enlarged and very early the 
nearest lymphatic glands become indurated. The ulcer itself is some- 
what granular, grayish in color and implanted upon more or less 
induration. Its surface is usually level with the surrounding parts. 
In the course of two to six weeks a confirmatory secondary syphilo- 
derm may be expected. According to Rhodes we must usually wait 
for this episode before venturing on a certain diagnosis. A super- 
ficial ulcer seated upon an indurated tonsil, rebellious to local treat- 
ment and accompanied by enlarged cervical glands is merely sus- 
picious until an eruption appears. Erythema of the fauces in 
syphilis is apt to develop in connection with a roseola of the skin 
and differs from a simple acute erythema in being less intensely red, 
comparatively free from swelling and sensitiveness, and limited by a 
distinct line of demarcation at the junction of the soft with the hard 
palate. The erythema may invade the tonsils and the pharyngeal 
membrane generally. 

The most common and obstinate and most dangerous, because 
highly contagious, lesion of syphilis met with in the air passages is 
the mucous patch. Although classified as a secondary lesion it may 
be met with early or late in the course of the disease. It is most 
apt to occur in conjunction with a papillary syphiloderm, but is more 
persistent than the cutaneous lesion. Mucous patches seldom give 



SYPHILIS OF THE PHARYNX. 



293 



rise to decided subjective symptoms, although they may be slightly 
sensitive to condiments, acids and hot or cold drinks. When the 
patches coalesce and cover a large area they may become decidedly 
painful. In its early stages a mucous patch looks like a small opal- 
escent erosion of the mucous membrane, resembling a surface that 




Fig. 



Syphilitic Ulcer of Right Pillar with Perforation of 
Velum on Left Side. (De Blois.) 



has been touched with nitrate of silver. There is seldom any indura- 
tion except in patches of long standing; in the latter case, several 
may coalesce and form a considerable ulcerated surface which may 
project more or less above the surrounding membrane. In the 



294 DISEASES OF THE NOSE AND THROAT. 

folds of mucous membrane it is not uncommon to see them present- 
ing a distinctly fungating appearance resembling condylomata. 

While these patches are very rebellious to treatment in some cases 
and show a persistent tendency to recurrence, in others they disap- 
pear promptly under superficial cauterization. Ordinarily there is 
no extensive or deep destruction of tissue, but when the patch has 
been exposed to prolonged irritation there may be a good deal of 
breaking down, resulting in true ulceration. When this state of 
things has been developed, the suffering of the patient may be con- 
siderable even to the degree of interfering with proper nutrition. 
This is especially the case when the soft palate is involved or the 
parts employed in the act of deglutition are affected (Fig. 101). 

Most of the ulcerating processes met with in syphilis are due to a 
breaking down of gummatous infiltration and are presented in two 
forms, the superficial and the deep. This division is purely an 
arbitrary one and the course pursued in each case is the same; 
namely, in the first place, a distinct induration which presently un- 
dergoes softening with rupture of the overlying mucosa and the for- 
mation of a ragged excavated ulcer of greater or less depth in pro- 
portion to the degree of infiltration. This manifestation of syphilis 
may be met with at almost any part of the pharyngeal wall and is 
productive of those deforming and disabling cicatrices which are so 
familiar. A gummatous process in the mucous membrane is exceed- 
ingly insidious and extensive damage may be done before the im- 
portance of the condition is appreciated; especially is this the case 
when the soft palate is involved. Irreparable damage may be done 
by the ulceration and by the subsequent cicatricial contraction (Fig. 
102). One of the most intractable conditions which we are called 
upon to correct is that of adhesion between the velum and the pos- 
terior pharyngeal wall resulting from this process. 

Recognition of an ulcer due to disintegration of gummy infiltra- 
tion is usually free from difficulty. The edges are sharply cut, sur- 
rounded by a well defined areola and the surface of the ulcer is more 
or less excavated and covered with purulent secretion and shreds of 
slough. In the early stages, however, before necrosis has taken place 
identification of the condition is less easy and many cases are re- 
corded in which a softening gummy tumor has been mistaken for 



SYPHILIS OF THE PHARYNX. 



295 



simple abscess and has been uselessly subjected to the knife (Fig. 

103)'. 

No lesions in the upper air tract respond more promptly to suit- 
able treatment than syphilitic manifestations, except those occurring 
in so-called malignant syphilis or in individuals in depressed general 




Fig. 102. Same as Fig. ioi, after Healing with Moderate Deformity. 
(Dc Blois.) 



health, and in those who persistently neglect treatment or violate 
hygienic laws. The treatment of these various lesions should be in 
line with that of syphilis in general, supplemented by certain local 
applications in some cases. The chancre usually requires no atten- 
tion beyond the use of an antiseptic gargle or, if it is very sensitive, 



296 



DISEASES OF THE NOSE AND THROAT. 



the occasional application of a local anesthetic like cocaine. A sim- 
ilar statement applies to erythema of the pharynx (Fig. 104). 

The mucous patch, on the other hand, requires more careful atten- 
tion on account of its contagiousness and for the additional reason 
that if it be allowed to persist it is apt to extend over more surface 




Fig. 103. Multiple Perforations of Palate from Softening Gummata. 
[De Blois.) 



and to greater depth. All irritants, in the first place, such as alcohol, 
tobacco and highly seasoned food, should be abandoned. Gargling 
with an alkaline solution, especially after eating, will be found sooth- 
ing and is usually effective. Repair of the patch in refractory cases 
may be expedited by careful application to its surface every second 



SYPHILIS OF THE PHARYNX. 



297 



or third day of the solid stick of nitrate of silver. The gummy 
tumor, before softening has ensued, may usually be speedily dissi- 
pated by rapidly increasing doses of iodide of potassium. When 
ulceration has taken place the necrotic tissue must be removed as far 
as possible, the surface of the ulcer kept clean, and occasionally cau- 




Fig. 104. Extensive Perforation of Velum in Syphilis. (De Blois.) 

terized with nitrate of silver ; at the same time the internal treatment 
being vigorously pushed. In many cases the action of the iodide 
should be aided by mercurials, either in the form of inunctions or 
internally and, in many cases, recovery may be assisted by the use of 
tonics. 

The contractions which result from syphilitic ulceration are fre- 



298 DISEASES OF THE NOSE AND THROAT. 

quently incurable. The cicatrices are usually perfectly characteris- 
tic. When adhesion of the velum to the pharyngeal wall is complete 
the patient is able to get his supply of air only through the mouth 
and, in consequence, the act of eating may be seriously impeded. It 
is very important, therefore, that we should if possible restore the 
normal nasal air tract. In some cases this is to a certain degree 
feasible ; in others the naso-pharyngeal cavity may be obliterated by 
adventitious bands to such an extent that its restoration is quite 
impracticable. The tendency to reformation of adhesions after their 
division is always very marked. To obviate this many devices have 
been proposed such as the passage of a strip of lint through the nose 
which is allowed to fall between the velum and the wall of the 
pharynx. A plate of lead suspended in the pharynx by threads 
passed through the nose, or a gutta-percha plate, has been successful 
in accomplishing the object. In several cases under my own care 
the patient was provided with a set of dilators of various sizes by 
which the opening was kept free ; but readhesion or contraction took 
place when systematic dilatation was suspended. When the adhe- 
sions are very thin and involve simply the margin of the velum a 
proposal made by Andrew H. Smith to cauterize the raw surfaces, 
after division, by means of monochloracetic acid has been found 
successful, the slough caused by the acid being retained long enough 
to allow the formation of protecting granulations. Various ingeni- 
ous plastic operations have been designed for removing these adhe- 
sions, some of which have been partially successful. Several cases 
operated upon by the late J. E. Nichols resulted very favorably. By 
his method a perforation of the velum is made on either side as far 
from the middle line as possible. Through these perforations setons 
are passed and worn for many weeks or until cicatrization around 
them is complete. The perforations are then joined by incisions 
carried from side to side between them, thus releasing the velum. A 
plate of gutta-percha or vulcanite is worn suspended from the nos- 
trils to keep the fresh surfaces apart until repair is complete. Al- 
though by these various methods we succeed in fairly restoring the 
air tract it is clear that the damage to the structure of the velum 
often must be irreparable. It is surprising how difficulty in swal- 
lowing and defects of speech may be overcome in course of time 



NEUROSES OF THE PHARYNX. 299 

and by the exercise of care, provided there has been no great loss 
of tissue. In cases of excessive destruction of palatal tissue the only 
resource is the adjustment of an obturator, or artificial palate. 



NEUROSES OF THE PHARYNX. 

Anesthesia is occasionally met with in the pharynx as a result of 
specific disease and of diphtheria. It has been observed in hysteria, 
in epilepsy and in general paralysis of the insane. As a result of 
progressive bulbar paralysis it is a much more serio'us condition than 
in the other diseases mentioned. It may be induced temporarily by 
morphine or the bromides. 

Treatment is seldom if ever necessary and in the presence of a 
grave central nerve lesion would be unavailing. 

Hyperesthesia of the pharynx occurs in acute inflammations and 
in those addicted to the excessive use of stimulants and tobacco, or 
it may be a manifestation of hysteria. It is frequently a serious 
obstacle to successful examination of the upper air passages, and 
may sometimes be overcome by the administration of bromides, by 
the local use of cocaine, or by sucking of ice. 

Paresthesia, in which abnormal sensations, as burning, pricking, 
or itching, may be complained of, is peculiar to hysterical females 
and neurotic subjects. An exciting cause may be frequently dis- 
covered in certain enlarged follicles of the pharynx or the base of 
the tongue, the destruction of which will result in cure. When the 
perverted sensation amounts to pain we recognize a distinct neural- 
gia of the pharynx, the treatment of which will depend upon its 
cause but which usually yields to local sedative applications. In 
hay fever a very persistent and annoying itching in the pharynx and 
in the roof of the mouth is often present. 

Spasm of the pharyngeal muscles occurs in various conditions 
such as hysteria, epilepsy, and in certain cerebral diseases. Clonic 
spasm, especially of the levator palati muscle, may be seen in con- 
nection with facial spasm or with a general chorea. Spasm of the 
pharyngeal constrictors has been traced in several cases to cerebral 
tumor. Faucial spasm may be symptomatic of an acute inflamma- 
tory condition, or it may occur in the course of hydrophobia. 



300 DISEASES OF THE NOSE AND THROAT. 

Paralysis of the pharynx is very frequently observed as a sequel 
of diphtheria or from disease of a central area in the medulla. It 
is one of the earliest symptoms of progressive bulbar paralysis. In- 
volvement of the soft palate is attended by forcing of food into the 
nasopharynx during attempts at swallowing and when paralysis of 
the glottis coexists fluids and food may invade the larynx and 
trachea. In bulbar paralysis other symptoms characteristic of the 
disease are more prominent and the prognosis is generally fatal. 
When occurring as a sequel of diphtheria or in connection with 
facial paralysis the prognosis is much more favorable and recovery 
takes place without the adoption of any special line of treatment, 
but it may be expedited by the use of tonics internally, strychnia and 
the local application of galvanism. In so-called myopathic paralysis 
a muscle, or group of muscles, is supposed to be impeded in action 
by infiltration with inflammatory products, the nerve supply not 
being primarily affected. Such conditions are rare but may follow 
simple inflammatory conditions as in cases reported by the author 
and others. 

Foreign bodies in the pharynx are usually sharp-pointed articles, 
such as fish-bones, pins, or sharp spicule of bone. Objects with 
smooth surfaces pass on, as a rule, into the esophagus or into the 
larynx. Symptoms are often very misleading, as the erosion of the 
surface which it causes generally induces a sensation as though the 
foreign body were still present. A sharp body, such as a needle, 
will frequently pierce the tissues and thence migrate to another part. 
It is often a very difficult matter to locate a foreign body in a nervous 
patient or when it has been long in situ and has excited irritability 
and inflammation. 

By the use of the laryngeal mirror, the parts having been anes- 
thetized with cocaine if necessary, the object may be discovered 
perhaps imbedded in the follicle of a tonsil or of one of the glands 
at the base of the tongue or lying in the hyoid fossa. Inspection of 
the parts may be, with advantage, supplemented by digital examina- 
tion and sometimes extraction may be effected by means of cotton 
wound on a probe, or upon the finger. In most cases the use of the 
forceps will be necessary. If left alone a small object may become 
encysted and do no further damage. On the other hand hemor- 



t 



FOREIGN BODIES IN THE PHARYNX. 3OI 

rhage may follow penetration of a blood-vessel, or sepsis may ensue 
from the development of phlegmonous inflammation. When a large 
irregular body becomes impacted in the lower pharynx its removal 
by external pharyngotomy may be required. 



THE LARYNX. 
CHAPTER XVII. 

ANATOMY AND PHYSIOLOGY OF THE LARYNX. METHODS OF 
EXAMINATION. 

ANATOMY AND PHYSIOLOGY. 

The larynx, or voice box, is composed of two large cartilages, the 
thyroid, or shield cartilage, the cricoid, or ring cartilage and a third 
somewhat smaller, the epiglottis, a leaf-like lid or valve which aids 
in diverting ingesta from the chink of the glottis. In addition to 
these single cartilages there are six smaller ones arranged in pairs, 
the arytenoid, the cornicula laryngis (Santorini), and the cuneiform 
(Wrisberg). All are closely bound together by ligaments, mem- 
branes and muscles. 

The cricoid, the foundation cartilage of the larynx, is attached 
below to the first ring of the trachea and articulates above with the 
thyroid. It is thicker and heavier posteriorly, where it supports the 
arytenoid cartilages, the latter being surmounted by the cartilages 
of Santorini, or cornicula laryngis, and the cartilages of Wrisberg, 
or cuneiform cartilages. The last three are called the cartilages of 
motion, because they are especially concerned in the movements of 
the vocal bands. 

The thyroid cartilage consists of two alae, united in front at an 
angle of 80 to 90 degrees to form the pomum Adami. Each ala is 
nearly square and has extending upwards and downwards from its 
posterior border the superior and inferior cornua, the former being 
attached to the hyoid bone by the thyrohyoid ligament, the latter 
articulating with a facet on the side of the cricoid cartilage. 

The arytenoid cartilages articulate with facets on the upper border 
of the cricoid, are triangular in shape on cross section and give 
attachment to all the intrinsic muscles of the larynx except the crico- 



ANATOMY OF THE LARYNX. 3O3 

thyroid. The anterior angle of each arytenoid is prolonged at its 
junction with the vocal band and is called the vocal process. It is 
plainly visible in the laryngeal mirror. The cornicula laryngis sur- 
mount the apices of the arytenoids, projecting backward and in- 
ward. The cuneiform cartilages are buried in the aryepiglottic 
folds in front of the cornicula. 

The thyroid and cricoid, which consist wholly of hyaline cartilage, 
and the arytenoids, which are hyaline except at their summits, are 
prone to calcify in advanced life. The others, yellow elastic carti- 
lages, show no such tendency. In addition to those mentioned sev- 
eral insignificant sesamoid cartilages are sometimes met with in the 
larynx. They are very inconstant and when present are of no 
importance. 

The cricoid and thyroid cartilages are united in front and at the 
sides by the cricothyroid membrane, and the thyroid is joined above 
to the hyoid bone by means of the thyrohyoid membrane and liga- 
ments. 

The larynx is bound to the first ring of the trachea by the crico- 
tracheal membrane. The posterior wall of the larynx is held in 
position by various muscles and is in relation with the anterior wall 
of the laryngopharynx. 

The epiglottis, a leaflike plate of yellow elastic cartilage, is at- 
tached to the angle of the thyroid below its median notch. It varies 
much in size and shape, is somewhat depressed and folded laterally 
upon itself during deglutition, and is joined to the base of the tongue 
by three bands known as the median and lateral glosso-epiglottidean 
folds. It is fixed to the hyoid bone by a membrane called the hyo- 
epiglottic ligament ; and from its base pass two bands of membrane 
which form the lateral boundaries of the superior aperture of the 
glottis known as the aryteno-epiglottidean folds. 

The thyrohyoid membrane is composed of elastic fibers uniting 
the hyoid bone with the upper margin of the thyroid cartilage and 
is bounded laterally by the thyrohyoid ligaments which pass from 
the superior cornua of the thyroid to the greater cornua of the hyoid. 
This membrane is pierced by the superior laryngeal nerve and arte- 
ries. 

The cricothyroid membrane is subcutaneous at its middle portion 



304 



DISEASES OF THE NOSE AND THROAT. 



and laterally is overlapped by the cricothyroid muscle. It is crossed 
by a small communicating- branch between the two superior laryngeal 
arteries, known as the inferior laryngeal or cricothyroid. Two or 
three small vessels penetrate the membrane and supply the mucous 
membrane of the larynx. 

The lateral portions of the cricothyroid membrane pass upward 





Fig. 105. Muscles of Larynx, Lateral View. (Deaver.) 
a, epiglottis ; b, aryepiglottic fold ; c, aryepiglottic muscle ; d, thyroepiglottic 
muscle ; e, thyroid cartilage ; /, thyroarytenoid muscle ; g, cricothyroid membrane ; 
h, cricoid cartilage ; i, trachea ; j , superior cornu of thyroid cartilage ; k, aryte- 
noideus muscle ; /, muscular process of arytenoid cartilage ; m, lateral cricoary- 
tenoid muscle; n, posterior cricoarytenoid muscle; o, facet for articulation with 
thyroid cartilage. 



from the inner border of the cricoid and form the inferior thyro- 
arytenoid ligaments, or the true vocal bands, extending from the 
vocal process of the arytenoid cartilages to the angle of the thyroid 



ANATOMY OF THE LARYNX. 



30S 



cartilage near its center. These bands are covered by the thyro- 
arytenoid and lateral cricoarytenoid muscles. 

The superior thyroarytenoid ligaments, ventricular bands, or false 
vocal bands, consist of fibrous tissue extending antero-posteriorly 
just above the true vocal bands. Muscular fibers within their folds 




Fig. 106. Muscles of Larynx, Posterior View. (Deaver.) 
a, laryngeal surface of epiglottis ; b, muscular process of arytenoid cartilage ; 
c, cricoid cartilage ; d, trachea ; e, aryepiglottic fold ; /, aryepiglottic muscle ; g, 
arytenoideus muscle ; h, thyroid cartilage ; i, posterior crico-arytenoid muscle ; / 
recurrent laryngeal nerve. 

are described by some anatomists as the superior or external thyro- 
arytenoid muscles. They assist the inferior thyroarytenoids (Fig. 

105). 

The muscles controlling the movements of the laryngeal cartilages 
are divided into two groups, extrinsic and intrinsic. The extrinsic are 
20 



3o6 



DISEASES OF THE NOSE AND THROAT. 



the sternothyroid, the thyrohyoid, the stylo- and palato-pharyngeus 
and the inferior constrictor of the pharynx. Of the intrinsic mus- 
cles the cricothyroid is attached to the front and side of the cricoid 
and to the lower border of the thyroid cartilage. The lower fibers 
pass to the border of the inferior cornua and act by pulling the 
cricoid directly backwards while the spreading fibers which form the 
rest of the muscle swing the cricoid upon the cricothyroid joints, pull- 
ing it backwards as well as upwards. Some anatomists erroneously 
describe the swinging or tilting movement as taking place in the 
thyroid rather than the cricoid, but most authorities agree that the 
origin and fixed point of the cricothyroid muscle are upon the thy- 
roid cartilage and that therefore the posterior are the movable ends 




Fig. 107. Scheme of Action of Posterior Crico-arytenoid Muscles. 
(Landois and Stirling.) 

of the vocal bands. For this reason Jurasz advocates calling the 
muscle " thyrocricoid " instead of cricothyroid. The practical effect, 
stretching of the vocal bands, is the same in either case. This mus- 
cle is a tensor of the vocal bands (Fig. 106). 

The posterior cricoarytenoid muscle arises from the cricoid car- 
tilage and is inserted into the outer angle or muscular process of 
the arytenoid cartilage. Its upper fibers rotate the arytenoid whilst 
the lower fibers pull the whole mass of the arytenoid outwards. It 
is, therefore, a dilator of the glottis, or abductor of the vocal bands 
(Fig. 107). 



ANATOMY OF THE LARYNX. 



307 



The lateral cricoarytenoid muscle springs from the upper border 
of the cricoid between the origin of the cricothyroid and the crico- 
arytenoid articulation, and is inserted into the forepart of the mus- 
cular process of the arytenoid. It rotates the cartilage inwards and 
draws it forwards, relaxing and approximating the cords. 

The thyroarytenoid muscle arises from the lower two thirds of 
the inner surface of the thyroid close to its angle and slightly from 
the cricothyroid membrane. It passes outwards and backwards and 
is inserted into the anterior surface of the arytenoid cartilage and 
to its base close to the attachment of the lateral cricoarytenoid mus- 
cle. The lower and inner portion is parallel with and blends with 
the vocal band. The upper and outer portion is placed immediately 
beneath the mucous membrane and overlies the ventricle. These 




Fig. 



108. Scheme of Action of Thyro-arytenoid Muscles. 
(Landois and Stirling.) 



two divisions of the muscle are sometimes known respectively as the 
inferior, or internal, and the superior, or external thyroarytenoids 
(Fig. 108). 

These muscles rotate the arytenoids and draw the vocal bands 
downward and inward and thus approximate them. At the same 
time they relax the vocal bands as a whole. Some fibers attached 
to the free border of the vocal band are said to be capable of making 
tense a portion only of the band, leaving the rest relaxed, thus re- 
sembling somewhat the stop action of the finger on a violin string. 
They also make the band thinner and wider. 



308 DISEASES OF THE NOSE AND THROAT. 

The arytenoideus muscle consists of transverse fibers passing 
across from one arytenoid cartilage to the other, and attached to 
their posterior surface. Superficially, oblique fibers pass from the 
base of one cartilage to the summit of the opposite cartilage. A few 
of the latter pass under the arytenoepiglottidean fold and side of 
the epiglottis, constituting the epiglottoarytenoideus muscle. This 
muscle approximates and depresses the arytenoid cartilages (Fig. 
109). 

The thyroepiglottideus muscle, a part of the thyroarytenoideus, is 
composed of fibers which extend from the thyroid cartilage to the 




Fig. 109. Scheme of Action of Arytenoideus Muscle. 
(Landois and Stirling.) 

arytenoepiglottidean fold and the outer wall of the pharyngeal pouch 
and epiglottis. 

The nerve supply of the larynx is derived from the laryngeal 
nerves, superior and inferior. The superior has two branches. The 
external is distributed to the cricothyroid muscle and sends a few 
filaments to the mucous membrane of the larynx; it is chiefly a 
motor nerve. The internal branch is larger and is purely sensory. 
It pierces the thyrohyoid membrane and distributes branches to the 
epiglottis and to the mucous membrane of the larynx as far down 
as the true vocal bands. 

The inferior, or recurrent, laryngeal nerve is the motor nerve of 
the larynx. It ascends between the trachea and the esophagus, 



ANATOMY OF THE LARYNX. 



309 



enters the larynx immediately behind the cricothyroid joint and 
divides into two branches, an anterior to the thyroarytenoideus, the 
cricoarytenoideus lateralis, and muscles of the epiglottis, and pos- 



e 


ef 


f E 




/— 






___ 


li- 


** \ 


■ 

1 






■' I 



Fig. 1 10. Nerves and Arteries of Larynx. (Deaver.) 

a, greater cornu of hyoid bone ; b, thyrohyoid ligament ; c, thyrohyoid mem- 
brane ; d, superior cornu of thyroid cartilage ; e, aryepiglottic muscle ; /, aryte- 
noideus muscle, g, posterior border of thyroid cartilage ; h, posterior cricoarytenoid 
muscle ; i, cricothyroid articulation ; j, cartilago tritacea ; k, internal laryngeal 
nerve ; /, superior laryngeal artery ; m, cricoid cartilage ; n, recurrent laryngeal 
nerve ; o, inferior laryngeal artery. 



terior branches to the posterior cricoarytenoideus and arytcnoideus, 
and communicates with the superior laryngeal by slender filaments 
near the posterior border <>\ the thyroid cartilage (Fig. no). 



3IO DISEASES OF THE NOSE AND THROAT. 

The arterial supply is derived from the superior and inferior thy- 
roid, the epiglottis receiving some branches from the dorsalis lin- 
gua; from the lingual. 

The aperture of the glottis is triangular in shape, bounded in front 
by the epiglottis, behind by the arytenoid notch and on either side 
by the arytenoepiglottidean fold. Between these folds and the wings 
of the thyroid on either side are shallow depressions known as the 
" pyriform sinuses." 

The cavity of the larynx is lined by mucous membrane, somewhat 
thick and red in color except over the true vocal bands where it is 
pale, thin and adherent. Numerous elastic fibers and mucous glands 
are found in the submucous tissue. The cavity is divided into two 
portions, the supra- and infra-rimal, the true vocal bands being the 
line of separation. Immediately above each vocal band lies the ven- 
tricle of the larynx, bounded above by the ventricular band, and 
externally by the thyroarytenoid muscle. It is lined by mucous mem- 
brane continuous with that of the larynx and from its anterior part, 
extending upwards about one half inch, is the laryngeal pouch, or 
" sacculus laryngis." Its mucous membrane contains many glands 
which supply secretion for lubricating the vocal cords. At its outer 
side are fibers of the thyroarytenoideus muscle, while on its inner 
side is an extension of muscular fibers of the arytenoepiglottideus 
known as Hilton's muscle or the compressor sacculi laryngis. 

The superior, or false vocal cords, or ventricular bands, stand 
further apart than the true vocal bands and between them and the 
arytenoepiglottic folds on either side is a shallow depression known 
as the fossa innominata. Their contour is full and round and they 
are covered by red, moist mucous membrane, while the true vocal 
bands are pearly white or opaline in appearance and present flat- 
tened surfaces as seen from above. On cross-section the latter are 
more triangular, and strictly speaking are neither bands nor cords. 
Their average length in the adult is seven lines (14 mm.). 

The rima glottidis, or triangular space between the vocal bands, 
is limited behind by the interarytenoid commissure, and in front by 
the thyroid cartilage. Its dimensions vary in respiration and phona- 
tion. The mfrarimal portion becomes almost circular below the 
vocal bands and is continuous with the trachea (Fig. in). 



PHYSIOLOGY OF THE LARYNX. 



311 



The larynx is spoken of as the organ of voice, and we are apt to 
lose sight of the important part played by other structures in voice 
formation until our attention is drawn to them by some defect in 

/ 




Fig. hi. Superior Aperture of Larynx and Dorsum of Tongue. (Deaver.) 
a, vocal band ; b, ventricular band; c, tonsil ; d, adenoid tissue at base of tongue; 
e, foramen cecum ; f, posterior wall of pharynx ; g, corniculum laryngis ; h, cunei- 
form cartilage ; i, epiglottis ; k, median glosso-epiglottic fold ; /, fungiform papillae ; 
in, circumvallate papillae. 

structure or function. The nasal chambers and the accessory sin- 
uses, the lips, the teeth, the tongue, the velum and pillars of the 
fauces, the trachea and lungs, as well as the shape and size of the 



312 DISEASES OF THE NOSE AND THROAT. 

larynx itself, all share in influencing the timbre and the pitch of the 
voice. The larynx is not even essential to audible and articulate 
speech, as has been shown in a famous case of complete laryngec- 
tomy in which the pharynx was entirely shut off from the lower air- 
track, the patient learning to speak and even sing by sucking in and 
storing air in his pharyngeal pouch (Solis-Cohen). Similar facility 
was acquired by a patient wearing a trachea tube for complete ob- 
struction of the larynx (Czermak) and by one also wearing a tube 
after an attempt at suicide by cutting his throat (Bourguet). The 
old idea that the epiglottis closes the larynx, like the lid of a box, 
during deglutition, has been supplanted by the view that it curls 
laterally in such a way as to direct the food into the pyriform sin- 
uses (Carmalt Jones). In a few cases, in which the epiglottis has 
been absent, destroyed by disease, or removed, its duty has been 
assumed by the ventricular bands, and no impression has been ob- 
served, either upon swallowing or speech. It is not very movable, 
the larynx rather rising to meet it in the act of deglutition. The 
ventricular bands assist in protecting the larynx against the invasion 
of foreign substances, but are not concerned in normal voice produc- 
tion. It was once thought that in the formation of the falsetto voice 
they pressed down upon the vocal bands in such a way as to limit 
their vibration (Mandl), but this view is not capable of proof. They 
substitute for the true cords when the function of the latter is abol- 
ished. The vocal bands are not flat, but on cross section are seen 
to be triangular or prismatic. Their free edges are composed of 
yellow elastic fibers by which their contour is preserved under vary- 
ing degrees of tension. They are lubricated by secretion furnished 
by the mucous glands of the sacculus laryngis, which opens into the 
ventricle of the larynx, the ventricle of Morgagni. A few mucous 
glands exist on the true cords. They are very numerous on the 
ventricular bands, and on the latter are also found irregular collec- 
tions of lymphoid tissue, the " laryngeal tonsil." The color of the 
vocal bands is pearly white or opaline. They are about one quarter 
of an inch shorter in the female than in the male, being about three 
fourths of an inch long in the latter. Vocal sound is caused by 
impact of the expired air upon their free margins. The interesting 
mode of action of the thvroarytenoid muscles, of which the vocal 



PHYSIOLOGY OF THE LARYNX. 3 I 3 

bands are considered by some to be the tendinous portion, has already 
been described. The bands move slightly with respiration, approach- 
ing - each other on expiration and separating a little on inspiration, 
unless the latter be forced, when the reverse is true. 

The aid of the extrinsic muscles, especially the sternothyroid, in 
securing efficient action of the intrinsic is essential, in order to fix 
the thyroid cartilage. The cricothyroid and thyroarytenoid muscles 
cannot come into full play without this preliminary fixation. Yet 
the abnormal use of the extrinsic muscles, as well as conscious or 
voluntary contraction of any of the laryngeal muscles, seems to be 
fatal to purity of tone and results in that disagreeable quality which 
is familiar to us as the " throaty " voice. The range of the speaking 
voice is very limited in most people and is modulated by infinite 
gradations. The tax upon the larynx in singing is much greater, 
because a wide range is covered, sometimes more than two octaves, 
and moreover the utmost precision in striking the intervals, never 
less than a semitone, must be assured. When we consider the com- 
plicated and delicate mechanism of the larynx we may appreciate the 
importance of favorable conditions, atmospheric and other, to the 
preservation and full development of the singing voice. Large 
demands are made upon the organism in general in vocal efforts of 
extraordinary character, hence the importance of maintaining the 
general health at a high standard if the best results are to be attained. 

The hygienic value of exercises in voice culture, regardless of any 
special musical talent, cannot be too highly estimated. The majority 
of people, unaccustomed to athletics or outdoor sports, seldom if ever 
use their lungs to full capacity. The respiratory gymnastics, in- 
volved in well-directed vocal training, undoubtedly have a tendency 
to overcome a predisposition to pulmonary weakness and contribute 
to an improved vitality which enables one more successfully to resist 
disease in general. The local effect of such exercises, under intel- 
ligent guidance, is often marked in a disappearance of small collec- 
tions of hyperplasia in the mucous membrane of the air track, or 
even on the vocal bands themselves, and in a correction of a tendency 
to inflammatory outbreaks. The relation of nasal and pharyngeal 
anomalies to functional and ultimately structural derangements of 
the larynx has been already discussed. 



314 DISEASES OF THE NOSE AND THROAT. 

Aphonia, or loss of voice, and dysphonia, or hoarseness, are symp- 
toms of various diseases to be considered. Anything which inter- 
feres with the mobility, or elasticity, of the vocal bands may 
act as a cause. Similar results may follow inflammatory, or 
obstructive, lesions elsewhere in the air track, the bands them- 
selves remaining unimpaired. The causes affecting the vocal 
bands may be divided into inflammatory, muscular, or arthritic, and 
neurotic. As an example of the first the voice of a laryngitis may 
be mentioned. In acute laryngitis it may be entirely lost; in chronic 
laryngitis it is whispering, or raucous. In rheumatic laryngitis the 
muscles are crippled, or there may be anchylosis of the cricoarytenoid 
joint. In either case approximation of the vocal cords is difficult 
or impossible. Illustrations of neurotic aphonia are met with in 
hysteria, which is purely functional, and in disturbed innervation 
from pressure of an aortic aneurism on the recurrent nerve. 

The vocal bands resemble the reed of a wind instrument only in 
the fact that their margins vibrate under the influence of the passing 
column of air. The character of the voice is infinitely diversified 
by elongation and shortening, widening and narrowing of the 
bands constantly taking place in the production of different tones. 
This extraordinary combination of actions distinguishes the natural 
larynx absolutely from every possible artificial mechanism. When 
we consider how manifold are the elements concerned we shall begin 
to realize what a complicated process vocalization is and how futile 
must be any attempt to formulate a theory of voice culture univer- 
sally applicable. 

The shape and dimensions of the resonating cavities, a normal con- 
struction and healthy action of all parts of the vocal apparatus, even 
the texture of the tissues themselves, and more than all the musical 
intelligence and temperament of the individual participate in the 
formation of a voice of satisfactory power and pleasing quality. 

METHODS OF EXAMINATION. 

In laryngoscopy, or examination of the larynx, the position of the 
patient, and the source of light are similar to those in examining the 
nose and pharynx. The only additional instrument needed is a large- 



EXAMINATION OF THE LARYNX. 



315 



sized mirror to be introduced into the fauces with its reflecting sur- 
face downwards. It is a good plan always to begin examinations 
of the larynx with the tongue at rest in the floor of the mouth ; then, 
to depress it by means of a tongue-spatula; and finally, to support 
the protruded tongue between the thumb and finger. The laryngeal 
mirror should be as large as the fauces will conveniently accommo- 
date in order to obtain a complete image (Fig. 112). The patient 
should be directed to breathe quietly, to open the mouth without 
extraordinary effort, and care should be taken to avoid violent trac- 
tion upon the tongue as well as dragging it downward upon the 
lower incisor teeth. It is rather more satisfactory for the examiner 




Laryngeal Mirrors. 



himself to hold the patient's tongue except in the exercise of certain 
manipulations in which both hands are required, the movements of 
the head being- thus under better control. 



ging and it is frequently impossible to obtain a satisfactory view 
without the aid of cocaine, or some form of local anesthesia, or care- 
ful preliminary training of the patient. Sometimes it is a good plan 
to direct him to close his eyes during the examination. If gagging 
occurs, panting respirations will sometimes overcome the intoler- 
ance; or a four per cent, solution of cocaine may be. sprayed into 
the fauces. It is well to avoid the pharyngeal wall, if possible, but 
the mirror should be introduced boldly, its back against the velum, 
which should be lifted firmly upwards. Timidity in this procedure 
frequently will be more disastrous than firmness. In introducing the 
mirror it is sometimes annoying to meet with considerable obstruc- 
tion from upward curvation of the dorsum of the tongue which 
may be overcome by directing the patient to phonate a long " ah." 
After the mirror has been placed in position, the interior of the 



i6 



DISEASES OF THE NOSE AND THROAT. 



larynx may be brought into view by causing the patient to sing a 
falsetto "' e " or to make the attempt, which is sufficient. In this 
way the movements of the cords and the arytenoids may be studied. 
In some instances the peculiar shape of the epiglottis is a source of 
difficulty. Occasionally it will be observed to drop over the rima 
glottidis and cut off the view of the cords. In other cases a lateral 
compression is noticed giving the conformation known as the 
" omega " shaped epiglottis. The impediment 
thus offered may be sometimes overcome, if 
an examination is imperative, by dragging 
the epiglottis upwards and forwards, after 
cocainizing, by means of a sharp hook or 
tenaculum. The long tongue spatula of 
Bleyer or Escat is said to be particularly use- 
ful in examining children. The former has a 
curved end intended to be passed over the epi- 
glottis, the latter has a bifurcated extremity, 
the prongs of which rest in the sinus pyrifor- 
mis on either side (Fig. 113). The left index 
finger makes a very good tongue depressor 
and to children is less terrifying than an in- 
strument. Traction may be made by hooking 
it around the hyoid bone. The first larvngeal object seen in the 
mirror will be the tip of the epiglottis. We shall then identify the 
ventricular bands and the prominences of the arytenoids and finally 
the white vocal bands. It should always be remembered that the 
laryngeal image is transposed antero-posteriorly, that is, the parts 
seen in the upper part of the mirror while apparently most remote 
are really at the anterior wall of the larynx ; those at the lower bor- 
der are most distant and at the posterior commissure. The first 
view, especially in an untrained patient and without cocaine, will 
give us the most reliable picture of the laryngeal cavity, since pro- 
longed examination excites muscular contraction and causes more 
or less congestion which may be misleading. It is sometimes pos- 
sible by tilting the mirror to get a view of the entire laryngeal wall 
and even a glimpse into the ventricles, as well as a considerable 
distance down the trachea, and in rare cases the bifurcation 




Fig. 113. Escat's 
Tongue Depressor. 



EXAMINATION OF THE LARYNX. 317 

is visible. As a rule the anterior wall of the larynx is best seen 
in the ordinary method of making the examination. In order 
to get the posterior wall of the larynx and trachea more fully exposed 
we sometimes adopt what is known as the position of Killian, in 
which the patient is made to stand erect while the examiner is seated, 
the head of the subject being bent forward so that the eye of the 
observer looks upward at an angle. This is found to be very useful 
in case of certain lesions which are met with at the posterior wall of 
the larynx. A similar object is attained in the suggestion of Mer- 
mod in which a second mirror attached at a right angle to the laryn- 
goscopy mirror is introduced into the cavity of the larynx. Obvi- 
ously it has a limited application. The misnamed instrument, the 
" autoscope " of Kirstein, is intended to give a direct, or " ortho- 
scopies view of the larynx. Its essential part is a long spatula or 
concave piece designed to grasp the base of the tongue on either 
side of the median glossoepiglottic ligament. In the meantime the 
patient's head is extended forcibly in such a way as to bring the 
anteroposterior axis of the mouth in line with the vertical axis of 
the trachea. At the same time firm pressure upon the tongue drags 
the epiglottis forward and upward, and provided the patient is capa- 
ble of submitting to this irksome position, in some cases a very good 
direct view of the larynx may be obtained. It is necessary for the 
patient to be seated and the examiner to stand in front of him and a 
brilliant source of light should be provided. The original Kirstein's 
instrument had attached a small electric lamp, but the usual methods 
of reflection will serve the purpose. This mode of examination is 
claimed to be especially applicable to children and for the removal 
of foreign bodies— but, with a little tact and patience, the ordi- 
nary methods will usually succeed. 

It is possible to gain additional information in some cases by other 
methods than inspection. External palpation, for instance, will show 
us whether the thyroid is, or is not, symmetrical, whether abnormal 
sensitiveness is present, and it is claimed to be of especial value in 
detecting laryngeal paralysis, which might not otherwise be recog- 
nized, in consequence of the absence of normal vibration on the 
affected side. A certain amount of corroborative evidence may be 
obtained by auscultation of the larynx ; and it is a good plan for the 



3 1 8 DISEASES OF THE NOSE AND THROAT. 

examiner to educate his ear to the character of the voice, since in 
certain conditions peculiar qualities are more or less charac- 
teristic; for example, the rough, harsh voice of syphilitic laryn- 
gitis, the weak whispering voice of tuberculosis, and the metallic 
voice and especially the cough of some forms of paralysis are in some 
degree distinctive. In addition we may get some valuable points, 
especially in cases of laryngeal neoplasm, by the use of the probe. 
We may learn, for instance, some facts as regards the mobility and 
the density of a tumor of the larynx. Above all one should never 
permit one's interest in the examination to prolong the process beyond 
the endurance of the patient, and if local hyperesthesia is so great as 
to prove insurmountable, it will certainly be better to postpone at- 
tempts to get a view until the patient has been rendered manageable 
bv the various methods of training: elsewhere described. 



GENERAL THERAPEUTICS. 

The fact should never be forgotten that the larynx is only one 
part of the human machine, and that many laryngeal affections are 
aggravated and perpetuated as well as caused, by some systemic dis- 
turbance. One of the first indications in nearly every laryngeal 
lesion is to secure, as far as possible, absolute rest, not only as regards 
actual talking but by the avoidance of functional excitement as in 
the act of laughing, and in violent exercise. The use of tobacco and 
alcohol should be prohibited in acute and in many chronic conditions. 
The digestion must be looked into and a tendency to constipation 
corrected. Cough resulting from disease in the lungs or bronchi, or 
of a reflex character, must be investigated and its cause removed if 
possible. The habit of clearing the upper air passages by the act of 
hawking is a source of irritation, and is usually excited by some 
trouble in the nasal chambers. It is, therefore, important that in all 
cases of laryngeal disease the nose and pharynx should be carefully 
examined and be relieved of anomalies and deformities, although the 
immediate subjective symptoms the latter induce seem to be insig- 
nificant. 

As to local therapeutics we may medicate the larynx by means of 
powders, inhalations, vapors or sprays. Fumigations are seldom 



GENERAL THERAPEUTICS OF THE LARYNX. 3I9 

resorted to in laryngeal difficulties and the use of lozenges and gargles 
in any form is, of course, futile. Gargling the larynx by the method 
of Guinier has been described and practised occasionally, but it is 
by no means easy of accomplishment and cannot be considered very 
practical. Insufflations in laryngeal disease are limited with advan- 
tage to ulcerative processes. In some forms, as tuberculosis and car- 
cinoma, certain powders seem to be beneficial in relieving the pain 
and promoting asepsis. Medicated steam and vapors are most grate- 
ful in the simpler forms of acute inflammation. 

For routine treatment the use of the spray is generally prac- 
ticable and much more satisfaction will be obtained by employing 
the straight tube, the patient being taught to practice deep inhala- 
tions at the moment of application. Used in this way little or no 
resistance or spasm of the larynx is likely to be excited ; whereas, a 
blast of air directly upon the vocal bands, even if the solution it con- 
veys be not very irritating, will frequently produce distressing or 
alarming spasm. A similar objection applies to the introduction of 
applicators carrying medicaments into the larynx. The latter are 
reserved for inveterate cases of laryngitis in which the sensitiveness 
of the larynx is so obtunded that little or no contraction is excited 
by the presence of a foreign body. The sponge probang and brush 
of the early days of laryngology have been pretty generally discarded. 
The special form of medication to be applied, whether antiseptic, 
astringent, sedative or stimulant, will depend upon the particular 
lesion to be treated. These matters, as well as the question of in- 
strumentation, will receive consideration under appropriate sections. 
We sometimes secure good results from some form of external ap- 
plication, either in the line of depletion, as with leeches, counter- 
irritation with iodine or the blister and, in certain acute and subacute 
conditions, Leiters coil, or a form of water poultice, will serve as 
revulsives. 



CHAPTER XVIII. 

DISEASES OF THE LARYNX. ANEMIA AND HYPEREMIA. LARYNGEAL 

HEMORRHAGE. ACUTE AND CHRONIC LARYNGITIS. CHORDITIS 

TUBEROSA, OR VOCAL NODULES. CHRONIC SUBGLOTTIC 

LARYNGITIS. ATROPHIC LARYNGITIS. 

ANEMIA OF THE LARYNX. 

Anemia of the larynx may be observed in connection with general 
anemia, or as a pretubercular condition. In the chronic form of 
tuberculosis we find the laryngeal mucosa distinctly pale, even inde- 
pendently of structural changes. In chlorosis, in neurasthenic con- 
ditions, and especially in young girls about the age of puberty it is 
often seen. It merits especial attention as a forerunner of tubercu- 
losis. 

HYPEREMIA OF THE LARYNX. 

Hyperemia of the larynx may result from overuse of the voice, 
from the abuse of alcohol and tobacco, and is, also, observed in cer- 
tain occupations in which one is exposed to irritating atmosphere, 
smoke, dust, or chemical fumes. It is most marked where the tissues 
are lax, as on the aryepiglottic folds and ventricular bands ; on the 
epiglottis and vocal bands it is less pronounced. It is also met with 
in the course of various exanthemata, either antecedent to or asso- 
ciated with skin lesions characteristic of these diseases. It may be a 
chronic, so to speak, normal condition in habitual voice-users, espe- 
cially baritones and basses. 

HEMORRHAGE OF THE LARYNX. 

Hemorrhage of the larynx is a rare occurrence and seldom has any 
significance. It is extremely unusual to see a laryngeal hemorrhage 
in tuberculosis, although the sputa may be stained with blood, espe- 
cially after violent attacks of coughing; whereas, in the ulcerative 
stage of carcinoma it is not infrequent. It may result from trauma- 

320 



ACUTE LARYNGITIS. 32 I 

tism, or from a foreign body, and has been met with in the course 
of syphilis as a consequence of destructive ulceration extending from 
the larynx to the base of the tongue and involving the lingual artery. 
It is seldom of sufficient moment to demand attention. A simple 
spray of astringent character will usually control it. Some writers 
recognize a so-called " hemorrhagic laryngitis," the main feature of 
which is the formation of scabs composed of coagulated blood adher- 
ing especially to the vocal bands, rather than a free bleeding. Gott- 
stein regards it as a form of laryngitis " sicca," to be referred to 
later. 

ACUTE LARYNGITIS. 

Inflammation of the larynx may occur at any age or in either sex. 
It is more often met with in those exposed to severe weather or sud- 
den changes of temperature and is rather more common in males 
in consequence of their particular occupations. 

The causes of laryngitis are those affecting mucous membranes in 
general. Sudden changes in atmospheric conditions from hot to 
cold, mouth breathing due to nasal stenosis, damp clothing, espe- 
cially in voice-users, functional activity of the larynx in bad air, or by 
a bad method, or to excess, are among the most frequent. 

Predisposing causes are a depressed state of the system and gastro- 
intestinal disturbances. Previous attacks of inflammation are thought 
to establish a proclivity and it is not unreasonable to suppose that the 
mucosa is rendered more vulnerable by preceding disease. 

In the various exanthemata inflammation of the larynx is observed 
which differs in no respect from simple catarrhal laryngitis except 
that, in some varieties, the laryngeal condition is characterized by the 
development of lesions similar to those occurring upon the skin. In 
chicken-pox, for example, vesicles are observed upon the epiglottis 
which break and resemble aphtha;. In measles, diffuse patches or 
macula; frequently occur. In scarlatina the laryngitis is occasionally 
complicated by the formation of a pseudo-membrane and an unusual 
degree of edema is apt to develop especially when renal complications 
arise. In the laryngitis of typhoid fever a decubitus ulcer may 
develop or ulceration involving the lymphoid tissue resembling that 
of Peyer's patches is not infrequently noticed. The laryngitis of 
21 



322 DISEASES OF THE NOSE AND THROAT. 

erysipelas is rare and exceptionally dangerous when the phlegmonous 
type is assumed. 

The pathology of acute laryngitis resembles that of inflammation 
of other parts of the air track except that the catarrhal product is 
deficient in mucus owing to the relative scarcity of glandular tissue. 
In the first stage, as elsewhere, there is active hyperemia with dry- 
ness, followed by tumefaction of the membrane and serous exudation 
which finally becomes tenacious and turbid from the admixture of 
epithelial cells and leucocytes. In the majority of cases resolution 
takes place and the parts resume their normal appearance without 
change. In other cases the condition lapses into one of chronic in- 
flammation. In some instances erosions of the mucosa take place 
but no true ulcerative process is observed. 

The first symptoms noticed are usually slight hoarseness, a ten- 
dency to cough, and subjective sensations of dryness and tickling, 
sometimes with a feeling of constriction. The use of the voice is 
uncomfortable and even painful in aggravated cases. Sometimes the 
voice is completely lost early in the attack. In children the swelling 
of the mucous membrane produces more impediment to respiration 
in consequence of the relatively smaller dimensions of the larynx in 
the young but it seldom becomes serious unless complicated by edema. 
There may be slight pyrexia especially in children or nervous indi- 
viduals ; and in sleep the breathing may be somewhat noisy or stri- 
dent. In the mirror the mucous membrane is seen to be uniformly 
congested, or injected vessels may be identified at various regions. 
Occasionally when the coughing is very violent rupture of small ves- 
sels may take place and the sputum is tinged with blood. The vocal 
bands lose their pearly hue or may be concealed by swelling of the 
ventricular bands. 

The treatment should be more active in the case of children than 
in adults, although in the latter a laryngitis should never be neglected, 
owing to its weakening effect upon the membranes and the possi- 
bility of a chronic condition supervening. It should begin with 
a calomel purge, fractional doses, one tenth of a grain, being 
given every half hour until characteristic effects are produced. 
The patient should be kept in a warm even temperature, may 
be given hot drinks to promote the action of the skin and should be 



ACUTE LARYNGITIS. 323 

prohibited the use of the voice. If cough is a prominent symptom it 
should be controlled by the use of an opiate, preferably codeine or 
heroin, and by means of steam inhalations. The compound tincture 
of benzoin in water at the boiling point, one drachm to the pint, makes 
a soothing medicated vapor useful in these cases. It is said that 
dilute nitric acid in doses of from ten to fifteen drops every half hour 
for four or five doses, and then at longer intervals for a few hours 
will enable a singer or a public speaker to use his voice provided the 
remedy be resorted to at an early stage. The relief from this meas- 
ure is only temporary and it is, by no means, to be recommended 
except in cases of emergency. Menthol inhalations, or vapors of 
menthol, applied by means of the atomizer or nebulizer, will often 
give relief, the strength of menthol being about five grains to the 
ounce of fluid albolene. It is well in using the spray in these acute 
conditions to employ the straight rather than the down tube, the 
patient being instructed to inhale at the moment the spray is formed. 
It is unwise to use too much energy in local treatment. All applica- 
tions should be emollient and protective. 

We may secure relief by the external application of a water poul- 
tice, a piece of flannel wrung out in hot water, applied next the skin 
and covered with a larger piece of oiled silk, known in Germany as 
the Priessnitz compress, this being renewed at intervals and worn 
until improvement is well established. If the case is seen in the early 
stage it is sometimes possible to abort it by external counter-irrita- 
tion, depletion by means of leeches, or the application of Leiter's 
ice- water coil. By far the most important indication of all, in cases 
of acute laryngitis, is to enforce absolute rest. The patient should 
be isolated so far as possible, kept in an equable temperature and not 
allowed to use his voice in any way. In the event of the develop- 
ment of edema to a threatening degree it will be necessary to resort 
to scarification or puncture of the swollen tissues with Tobold's con- 
cealed lancet. If relief is not obtained in this way the question of 
intubation or tracheotomy is before us. The former, in several cases 
recorded, has given most excellent results, but if the edema is situ- 
ated high in the larynx it may be ineffectual on account of the occlu- 
sion of the upper orifice of the tube by the overhanging tumefaction. 
Or the serous infiltration may extend bcvond the lower end of the 



324 DISEASES OF THE NOSE AND THROAT. 

tube. In still other cases it may constitute what has been termed a 
" solid edema," upon which scarification makes no impression. In 
such case relief must be obtained by passage of a catheter through 
tlu' stenosed air track, as proposed by McEwen, or by a tracheotomy. 
Usually edema affects the vestibule of the larynx where it is within 
reach, but cases have been reported by Semon and by Risch in 
which the process was limited to the vocal bands. An extraordinary 
obstacle was met with by Casselberry in attempting an intubation for 
edema of the glottis. The jaws were so firmly fixed by spasm of 
the masseter muscles as to render opening of the mouth impossible. 
It is advisable to select a tube rather under the size indicated by the 
age of the patient and in adults it may be passed under the guidance 
of a laryngeal mirror. A combination of scarification with intuba- 
tion may be efficacious when the tube is found too short to compress 
all of the swollen area. In a case recorded by W. F. Brook efforts 
to introduce the tube lacerated the tissues and released the effused 
serum. All the evidence seems to show that a trial should be made 
of these measures before resort is had to the more formidable exter- 
nal operation. Fortunately, owing to the fact that simple catarrhal 
inflammation does not invade the submucous areolar tissue to any 
extent, edema as a complication of an acute laryngitis is very excep- 
tional. By propagation from the pharynx, as pointed out by Sestier, 
it is much more common, and it is sometimes consecutive to disease 
involving the perichondrium or the cartilages of the larynx. Sec- 
ondary to syphilitic or tubercular infiltration it is more apt to be a 
chronic than an acute edema and seldom demands attention. Fauvel 
refers to it as being possibly the first symptom of renal disease, yet 
Mackenzie affirms that he once examined 200 cases of Bright's dis- 
ease without discovering a single instance of edema of the larynx. 
Local depletion by means of leeches applied over the larynx exter- 
nally and spraying the fauces and larynx at intervals with a solution 
of suprarenal extract may relieve the turgid structures. In this 
connection the experience of S. Solis-Cohen in a case of asthma in 
which acute edema of the palate, pharynx and epiglottis followed a 
free application of the suprarenal-chloretone solution is of interest. 
A disease of which the laryngeal edema may be symptomatic must 
of course receive appropriate treatment. Primary " edematous 



CHRONIC LARYNGITIS. 325 

laryngitis " is an exceedingly rare phenomenon. Edema of the glot- 
tis as a symptom or sequel of disease is not infrequently observed and 
occasionally reaches proportions to excite alarm or involve danger. 
In the convalescent stage of acute laryngitis it may be necessary to 
brace up the relaxed membranes by means of mild astringent applica- 
tions ; the one preferred at the present time is a ten or twenty-grain 
watery solution of alumnol. Preparations of iron, chloride of zinc 
and nitrate of silver are more distasteful and offer no superiority. 
Within recent years many new silver combinations have been offered. 
Among the most promising is silver vitelline, or argyrol (Barnes and 
Hille), a proteid containing thirty per cent, of silver. It is very 
soluble, is absolutely free from irritating or caustic properties, and 
possesses great penetrating power owing to the fact that it does not 
precipitate albumen or sodium chloride. Hence we may expect the 
most brilliant results in derangements supposed to be dependent upon 
invasion of the submucous structures by bacterial organisms. 



CHRONIC LARYNGITIS. 

Chronic laryngitis is, as a rule, a sequel of the acute form, or may 
reach the larynx by extension from the pharyngeal cavity. By far 
the larger number of cases of chronic laryngitis owe their origin 
primarily to a nasal stenosis or disease in the nasal chambers which 
causes mouth-breathing or some change in the condition of the air 
supplied to the lungs as regards purity, temperature, or moisture. 
The abuse of alcohol and tobacco, exposure to irritating vapors in 
certain occupations, excessive use of the voice as met with in open- 
air speakers and street hawkers, are frequent causes. In addition 
certain derangements of the fauces, such as hypertrophied tonsils or 
an elongated uvula, are predisposing causes. The influence of cer- 
tain diatheses, as gout and rheumatism, should not be overlooked. 
Sooner or later in the condition of chronic laryngitis, a prolifera- 
tion of connective tissue cells takes place resulting in thickening of 
the tissues, this thickening not only involving the epithelial layer but 
the submucosa as well. Structural changes may invade the muscu- 
lar tissues. Involvement of the framework of the larynx is met 
with only in the existence of constitutional trouble, such as syphilis. 






326 DISEASES OF THE NOSE AND THROAT. 

tuberculosis, or malignant disease. Frequently, the pathological 
changes are circumscribed and affect a very limited area of the mu- 
cous membrane, constituting what is known as " singers' nodes " or 
chorditis tubcrosa of Tiirck. These developments are most frequent 
at the junction of the anterior with the middle third of the vocal 
bands. Sometimes the node is on the margin and again on the upper 
surface of the band and apparently incorporated with it. In the 
former case if the lesion is unilateral a depression may be seen at a 
corresponding point on the opposite cord. In many cases the lesion 
is bilateral and symmetrical. The cord as a whole is slightly if at 
all altered in appearance, or there may be a moderate amount of 
hyperemia, especially in the immediate neighborhood of the node. 
A similar circumscribed increase in connective tissue elements is 
sometimes noticed at the posterior commissure, or near the vocal 
processes, where the condition has been termed by Virchow pachy- 
dermia laryngis. 

The symptoms of chronic laryngitis are unmistakable. The voice 
may be partially or completely lost. It is apt to break unexpectedly 
and, in all cases, a condition of dysphonia exists and the patient is 
himself conscious of being compelled to make an extra effort to pro- 
duce a tone. After a night's rest there is always an accumulation 
of viscid tenacious secretion, the expulsion of which is accomplished 
by more or less violent cough and, at all times, the patient is dis- 
posed to cough especially in attempting to speak or after the use of 
the voice. Sometimes the voice, even when exceptionally hoarse, 
well clear up slightly after a few minutes' use. Patients frequently 
complain of a sensation of constriction or foreign body in the region 
of the larynx. Upon inspection with the mirror we find a congested 
mucous membrane with blood-vessels well defined upon the epiglot- 
tis or in the larynx itself. The tissues at the base of the cords are 
frequently more hyperemic than the margins of the cords them- 
selves ; or the margins of the vocal bands may be irregularly eroded. 
As a rule, the most marked changes are seen at the posterior wall of 
the larynx. Thickening of tissue occurring at that situation may 
interfere with approximation of the arytenoid cartilages and the 
aphonia may be due in part to the obstacle thus offered. Interference 
with the action of the intrinsic muscles of the larynx is mechanical 
and not a true paresis. 



CHRONIC LARYNGITIS. 327 

The prognosis depends upon the duration and extent of the inflam- 
matory process ; other things being equal, the more prolonged the 
condition the less likelihood of complete restoration of the voice. 
The larynx, once the seat of an aggravated degree of chronic inflam- 
mation, can never produce a tone of original quality and clearness 
even though all inflammatory symptoms have subsided. 

The treatment usually consists, in the first instance, of a reform 
of habits which tend to irritate the larynx, and of possible con- 
stitutional states which may induce a tendency to laryngeal hyper- 
emia. Attention should be paid to the diet and to the correction of 
gastrointestinal derangement. Good hygiene should be secured and, 
in many cases, tonics are indicated. 

Locally, stimulating inhalations of oil of pine, or nascent muriate 
of ammonia will be found useful, after cleansing the surface, if neces- 
sary, with alkaline solutions. In all cases attention should be paid 
to the condition of the upper air track and, before we can hope to get 
satisfactory results in chronic laryngeal inflammation, all nasal ob- 
structions and pharyngeal abnormalities should be removed. 

In chronic cases some benefit may be derived from astringent 
sprays, as applications of chloride of zinc, ten to thirty grains to the 
ounce in watery solution, or nitrate of silver, thirty grains to the 
ounce and upward. Silver solution should always be used in the 
larynx with great caution unless we know that our patient is tolerant 
of intra-laryngeal applications. It not infrequently happens that vio- 
lent and alarming spasm of the larynx is excited by the introduction 
of even the simplest medicament. It quickly subsides if the patient 
is able to take shallow rapid respirations instead of trying to breathe 
deeply. The use of brushes and swabs in the larynx is much inferior 
to that of the spray. Any intelligent person can be taught to inhale 
gently during the process and thus carry the spray into the laryngeal 
cavity. This method is effective and more agreeable than the intro- 
duction of a cotton wound applicator. The latter finds its place in 
connection with the use of caustic or concentrated solutions, the dif- 
fusion of which is to be avoided. Tobacco and alcohol should be 
interdicted and the patient should be warned to exercise great cau- 
tion in the use of the voice, in some cases removal to an equable 
climate must be insisted upon. Of late, much attention lias been 



328 DISEASES OF THE XOSE AND THROAT. 

paid to the effect of suitable vocal exercise upon hyperplastic changes 
of the mucous membrane in chronic laryngitis and especially in the 
thickening known as " singers' nodes." A careful study of these 
cases will sometimes teach us whether this mode of handling them 
is likely to be effective. In cases of long standing, when the nodes 
are very dense and extensive, we can hope to accomplish but little. 
In more recent cases it is possible that suitable exercise of the voice 
may be of advantage, the theory being that dispersion of the infiltra- 
tion or hyperplasia is effected by a so-called vocal massage of the 
laryngeal structures. The term used in this sense is certainly a 
misnomer. The spontaneous disappearance of the nodes under abso- 
lute rest is sometimes observed and the question arises whether the 
moderate use of the voice in such vocal exercises as are recom- 
mended is not practically a modified rest. 

The recent observations of Garel and Bernand fail to confirm the 
opinion of Frankel that the changes resulting in the formation of 
these nodes begin in the glandular structures. In some cases they 
proved to be small fibromyxomata ; in others the changes were in the 
mucous membrane and chiefly vascular. In their experience the 
nodes sometimes disappear spontaneously, the galvanocautery has 
often been employed with success, but ablation with cutting forceps 
is much to be preferred. From examinations of the tissues com- 
posing the nodes made by Rice, Kanthack, Chiari and other investi- 
gators it seems to be proven that they are not of glandular origin 
but consist mainly of connective tissue and epithelial elements. At- 
tention has been drawn by F. I. Knight to the confusion existing 
between this condition and a diffuse granular inflammation involving 
the whole cord, or trachoma of the vocal cord. As a matter of fact 
there may be few or none of the usual local signs of inflammation. 
The term chorditis is therefore open to criticism; moreover, it might 
be more appropriate to refer to these nodes as " vocal " rather than 
" singers' " nodules, since they occur not infrequently in those who 
do not sing. There seems to be no evidence to sustain the suspicion 
of a relationship between vocal nodules and a tuberculous diathesis. 
In reviewing the anatomy of the larynx reference was made to the 
curious distribution of the thyroarytenoid muscle to the margin of 
the vocal band. The interesting question suggests itself whether 



CHRONIC LARYNGITIS. 329 

persistent and oft-repeated tugging or strain upon certain fibers may 
not induce a hyperemia or even a minute hemorrhage to develop later 
a vocal nodule. 

It seems to be desirable to distinguish between " trachoma " of the 
vocal cord, a condition of diffuse inflammation resembling a granu- 
lar or follicular pharyngitis and involving the whole extent of the 
band ; " pachydermia laryngis," which is a hyperplastic overgrowth 
at the posterior commissure and in the neighborhood of the vocal 
processes ; and, finally, " chorditis tuberosa," or vocal nodules, iso- 
lated nodular masses usually seated at the junction of the anterior 
and middle thirds of a vocal band, commonly bilateral, often 
only on one side. However closely allied these conditions may be 
pathologically, their respective clinical pictures are sufficiently in 
contrast to award them separate titles. They equally impede phona- 
tion and are equally resistant to treatment, which should be invaria- 
bly preceded by careful elimination of morbid conditions in the supe- 
rior air track. 

The surgical treatment of these thickened tissues, sometimes advo- 
cated, as a rule should be avoided since there is great danger that 
the intralaryngeal manipulations, essential to the removal of a broad- 
based sessile overgrowth, will do more damage than the hyperplasia 
itself. Occasionally if the growth is pedunculated, or on the margin 
of the cord and in a well-trained subject it is possible to excise the 
little tumor with a small cutting forceps, or to destroy it with a 
fine electric cautery point. Capart divides the treatment of " sing- 
ers' nodes " into hygienic, medical and operative. Although several 
instances of spontaneous disappearance have been recorded, he be- 
lieves that even prolonged rest of the larynx has no beneficial effect 
except upon an associated laryngitis. He condemns local treatment 
by sprays and insufflations of astringents and antiseptics, and espe- 
cially cauterization with nitrate of silver and chromic acid as being 
either ineffective or positively dangerous, in consequence of a ten- 
dency for these agents to spread and cause violent reaction. In 
operative treatment are included ablation and destruction with the 
galvanocautery. For the former a light and very delicate forceps 
is advised. The galvanocautery is reserved for nodes too small to 
be grasped with forceps. 



330 DISEASES OF THE XOSE AND THROAT. 

At best the management of these cases is very discouraging. In 
most cases the forceps is not available, the use of the cautery demands 
the utmost skill and delicacy and is to be thought of only in trained 
and tolerant subjects, and finally the enforcement of absolute rest, 
while most essential, is almost impossible. 



CHRONIC SUBGLOTTIC LARYNGITIS. 

An inflammatory process sometimes seems to expend itself on the 
under surface of the vocal bands and the adjacent wall of the larynx. 
It often leads to considerable thickening and in the laryngeal mirror 
gives the image referred to by [Mackenzie as that of " a second vocal 
cord." The affected region is usually redder than normal and looks 
dense and firm. At first it is uniformly smooth, but in old cases 
may become somewhat irregular and even eroded. It has been de- 
scribed by Gerhardt as a chorditis vocalis inferior, but the process is 
bv no means limited to the vocal bands, a considerable area beyond 
them being involved. It is not common in this country. Some 
observers trace it to some constitutional diathesis, scrofula, syphilis, 
or tuberculosis, while others regard it as related to rhinoscleroma. 
The symmetry, color and density of the swellings, obvious to the eye 
as well as on examination with a probe, differentiate this disease from 
edema and from that rare variety of myxomatous degeneration to 
be described elsewhere. It has been mistaken for eversion of the 
ventricles, a lesion the occurrence of which is denied by many author- 
ities. Its chief title to importance rests on the fact that it may 
embarrass respiration to a degree necessitating an intubation or a 
tracheotomy. Systematic dilatation may be required or the hyper- 
trophied tissues may be reduced by excision or by applications of the 
galvanocautery. In some cases the movements of the vocal bands 
are decidedly interfered with by thickening or by infiltration of the 
muscles by inflammatory products and the voice suffers proportion- 
ately. In others the vocal bands move with normal freedom and may 
quite conceal the hypoglottic swelling during phonation. The prob- 
able relationship of this affection to a constitutional diathesis en- 
forces the importance of internal medication. Iron preparations, 
especially the iodide of iron, are said to be useful. Bosworth warns 



ATROPHIC LARYNGITIS. 33 I 

against the administration of iodide of potash, lest an edema add to 
the volume of the obstructing hyperplasia. Yet the cautious use of 
the latter drug seems to be indicated when there exists a suspicion 
of syphilitic taint. Local applications, other than those directed to- 
ward reducing hyperemia or 'actual removal of the infiltration are 
worse than useless. 

ATROPHIC LARYNGITIS. 

Pathological changes similar to those occurring in the nose and 
pharynx and resulting in atrophy may take place in the larynx, when 
there is presented the condition known as atrophic laryngitis, or 
laryngitis sicca. Some confusion has arisen from the use of different 
terms to indicate what are probably identical diseases, the blenorrhea 
of Stoerk, the ozena laryngis of Baginski, and so on, according to 
the prominence of a given symptom. As a matter of fact the dis- 
ease is extremely rare and is a sequel of an analogous condition in 
the air track above, which latter is actually the more important. The 
chief characteristic of atrophic laryngitis is a perversion of secre- 
tion, whereby the mucus having lost a proportion of its watery ele- 
ments tends to form crusts or scales which adhere firmly to the mem- 
brane. At times these scabs cling so closely that a little bleeding 
takes place when they are forcibly dislodged. They may consist 
largely of blood and have a very fetid odor, which they impart to the 
breath. The mucous membrane may be eroded and if the vocal 
bands are affected their margins are notched and irregular. The 
crusts may be seen at almost any part of the larynx or extending 
down into the trachea. In a case described by B. Tauber the larynx 
and upper part of the trachea were lined completely by a blackish 
cast of incrusted secretion which had to be removed daily with for- 
ceps. The voice may be completely absent until the desiccated 
secretion is expelled, and the crusts may be so thick as to cause 
dyspnea. Their presence is provocative of violent and often pain- 
ful paroxysms of coughing. In some cases there is more or less 
concomitant acute or subacute catarrhal inflammation, when the 
membranes are swollen and red, while Gottstein describes a chronic 
form in which the mucosa is dirty gray in color. This affection 
seems to be peculiar to adults and is said to be more common in 



12,2 DISEASES OF THE NOSE AND THROAT. 

women. It is not infrequently seen in those who use alcohol to ex- 
cess and in syphilitics. Massei and others maintain that atrophy in 
the larynx is a direct extension of a similar state in the pharynx, 
while Bosworth lays great stress on the theory that catarrhal proc- 
esses are limited by anatomical boundaries and do not extend by con- 
tinuity of tissue. In any case it is a clinical fact that the morbid 
process in the larynx is secondary to some abnormality, atrophic or 
other, in the nose or pharynx which compels mouth breathing or 
interferes with suitable purification of inspired air. The presence of 
certain bacteria in the secretions, especially the bacillus fetidus, is 
looked upon by some as an etiological factor, but by most observers 
as a coincidence or consequence. 

The prognosis and treatment resemble those applying to atrophy 
in other situations. If the process is not too far advanced the nor- 
mal function of the affected region may be restored by preliminary 
cleansing of the surface followed by soothing or slightly stimulating 
applications in an oily vehicle. The crusts may be softened with an 
alkaline spray, or may require detachment mechanically. Inhalation 
of benzoinated steam is grateful and helps to loosen the secretions. 
Kyle highly recommends embrocations of petroleum externally. In- 
ternal medication is needed if the general health is poor or in the 
existence of a constitutional dyscrasia. It has sometimes seemed to 
me that the prolonged use of large doses of iodide of potash rather 
predisposed to atrophy, yet it is an almost indispensable drug in 
syphilis. At best response to treatment is slow, and the nose and 
pharynx must first be free from disease. 



CHAPTER XIX. 

BENIGN NEOPLASMS OF THE LARYNX. 

A benign tumor of the larynx may be defined as one which shows 
nc tendency to general dissemination and does not recur after thor- 
ough removal. The latter part of the definition would seem to ex- 
empt one variety of benign growths, namely, papillomata, which do 
show a disposition to return after apparently complete extirpation. 
However, the presumption is that even with these recurrence is due 
to failure of complete removal, although many cases are on record 
in which apparently thorough resection followed by cauterization 
through a thyrotomy wound has proved ineffectual. 

In the etiology of benign tumors in general it may be said that any 
condition or circumstance which promotes hyperemia or catarrhal 
inflammation is a predisposing cause. Voice strain, local irritants, 
and a general tendency on the part of certain individuals to neoplastic 
formations, a " verrucous diathesis," are included among these causes. 
How far overuse or misuse of the voice should be considered a fac- 
tor is more or less of an open question in view of Morell Mackenzie's 
famous case of papilloma occurring in a deaf mute. The majority 
of cases of laryngeal neoplasm have been met with in the adult and 
in the male sex. There are on record several congenital cases. 

The symptoms include alteration of voice varying with the situa- 
tion of the tumor, cough, more or less interference with breathing, 
especially in children, spasm of the larynx, moderate concomitant 
inflammation in some instances, hyperesthesia amounting in excep- 
tional cases to actual pain, and in some varieties hemorrhage. 
Among rare phenomena associated with certain benign neoplasms 
noted by Fauvel may be mentioned salivation and perversion of the 
sense of taste. Impairment of voice varies from slight hoarseness 
to complete apbonia. and is more pronounced when the vocal bands 
arc involved, or when the growth is sessile and small than when 

333 



334 DISEASES OF THE NOSE AND THROAT. 

pedunculated even though voluminous (Czermak). The respiratorv 
disturbance is influenced more by the size of the tumor, although 
paroxysmal dyspnea may occur under excitement, on exertion, or 
when the glottic aperture is still further narrowed by sudden swell- 
ing from catarrhal inflammation. A change in position of a pedun- 
culated growth may have a similar effect. When inspiration is more 
impeded than expiration, the growth is probably above the vocal 
bands (Lewin). An extraordinary subjective symptom, or more 
properly premonition of laryngeal neoplasm, was recently detailed 
to me by a young man with papilloma. He is an amateur short dis- 
tance runner, and after a very keen competition he once noticed a 
feeling of intense heat in the region of the larynx followed by partial 
loss of voice, the former lasting for upwards of an hour and the lat- 
ter continuing through the following day. This was repeated afte'r 
several subsequent contests until the partial aphonia became perma- 
nent and he was led to seek relief. 

The tendency to malignant degeneration of benign growths in the 
larynx has been the subject of much controversy. The testimony is 
for the most part in refutation, Felix Semon finding ground from 
extensive statistics he has collected to maintain that it is less marked 
when operation has been done than when the tumors have been let 
alone. It must be admitted that new growths may become modified 
from their original type. For instance, a fibroma may grow more 
vascular and finally appear as a genuine angioma, or may undergo 
fatty degeneration. A case of transformation into a myxoma has 
been recently reported by Masucci. 

The verdict on this question must be that malignant degeneration 
of an innocent neoplasm as a result simply of irritation or trauma- 
tism is not proven. When a cancer germ shall have been identified 
it will be easier to believe in the possibility of such change. In the 
meantime the practice of endolaryngeal surgery may be continued 
in skilful hands without fear of instituting a malignant character in 
benign tumors of the larynx. 

The prognosis is good, unless the growth is excessive, or, as in the 
case of some papillomata, shows a propensity to recur, when the 
voice may be permanently more or less impaired. Several cases of 
spontaneous detachment and expulsion are on record, as in one of 



PAPILLOMA OF THE LARYNX. 



335 



four congenital cases reported by H. A. Johnson, in which a papil- 
loma was expelled during a paroxysm of whooping cough. As a 
rule the development of the growth is so gradual that ample time is 
given for a tracheotomy before indications of dangerous stenosis are 
presented. 

In order of frequency benign tumors of the larynx may be enu- 
merated as follows : papilloma, fibroma, cystoma, myxoma, angioma, 
enchondroma, lipoma, and adenoma. The most frequent by far is 
the first mentioned, papilloma. Papillomata commence in the papil- 
lae of the mucosa, involve the epithelial cells and form wartlike 
growths, called by Virchow pachydermia verrucosa. They are usu- 
ally situated on the vocal bands and at the anterior part of the larynx 
(Fig. 114). They rarely occur elsewhere and almost never at the 





Fig. 114. Papilloma of Larynx. (Schnitzler.) 

posterior commissure. A form of excrescence resembling papilloma 
occurring in tubercular laryngitis in the interarytenoid space is not 
entitled to be thus classified. They are frequently more or less 
pedunculated, some authorities to the contrary notwithstanding, and 
they usually develop rapidly, especially in children and, in most cases, 
occupy the supraglottic region. I have never seen a papilloma of the 
larynx which was not somewhat constricted at its attachment, in 
other words pedunculated, and in many cases fungous or cauliflower 
expansion of the mass of the tumor was very apparent. 

Fibroma is a neoplasm of adult life. It is usually sessile and 
single, situated on one or the other vocal band, varying in size from 
that of a millet seed to a hazelnut or, in rare cases, even almost fill- 
ing the laryngeal cavity (Fig. 115). Usually it is round, symmetri- 
cal and redder than the band to which it may be attached. A single 



336 



DISEASES OF THE NOSE AND THROAT. 



case of fibroma of the larynx has come under my observation, in 
which I removed a growth the size of a small pea from a vocal band 
with Mackenzie's forceps. Growths in this class are spoken of as 
soft fibromata or fibrocellular, when their structure is made up in 
large part of cellular elements. 

Cystomata have been met with in adult life as late as the sixty- 





FlG. 



Fibroma of Larynx on Phonation (a) and during Respiration (M. 



fourth year as well as in young children. They occur in the form 
of retention cysts of the muciparous glands at almost any situation, 
the vocal cords included (Fig. 116). The epiglottis seems to be the 
favorite site (Fig. 117). In a case of cyst of the epiglottis under 
my care several years ago a tumor the size of a hickory nut was 
attached by a long pedicle to the left margin of the epiglottis. That 
organ was dragged downwards by the tumor so as to conceal the 
interior of the larvnx. The tumor itself was not to be seen until 




Cyst of Larynx. (Ingals.) 



forced into view by the act of retching. It was easily removed with 
the cold-wire snare. In some cases in which the tumor was small 
and sessile simple incision has been sufficient to effect a cure, as in a 
case described by Payson Clark, in which the tumor, attached to a 
vocal band, could not be seized with forceps. It was therefore in- 



CYSTOMA OF THE LARYNX. 337 

cised with a concealed lancet. A little milky fluid escaped, and the 
cyst walls collapsed and shrank away. 

These neoplasms are neither sensitive nor vascular. It is well 
enough to cocainize the parts before removal is attempted, but any 
special precautions against hemorrhage are superfluous. The diag- 
nosis is usually clear. They are pedunculated and elastic and are 
more or less translucent, provided their contents are fluid and serous, 
but not if they contain gelatinous, colloid, or bloody material as in 
certain rare cases (Lefferts). The size of these growths varies. 
They may become so large as to necessitate a tracheotomy or even 
as in one case a pharyngotomy. They may occur at any age. One 
about the size of a hempseed has been found post mortem in a child 




Fig. 117. Cyst of Epiglottis. 

fourteen days old (Abercrombie), and one the size of a hazelnut is 
reported to have caused the death of an infant thirty-seven hours 
after birth (Edis). 

Myxoma may occur in two forms, either as a pedunculated tumor 
generally situated upon a vocal band, or in the form of a sessile dif- 
fuse mass, a sort of myxomatous degeneration. 

A case of diffuse subglottic myxoma came under my observation 
several years since in the person of a woman forty-eight years of 
age, who had been hoarse and annoyed by wheezing respiration for a 
year or more (Fig. Il8). She had some cough and was supposed l<> 
have asthma. No pulmonary lesion could be detected, but with the 
22 



3$?< DISEASES OF THE NOSE AND THROAT. 

laryngoscope a mass of finely tabulated tissue could be seen extend- 
ing from the under surface of the vocal bands down into the trachea 
and encroaching upon the air-tube. Portions of this mass were 
removed with Mackenzie's cutting forceps until it became evident 
that the lower limit of the growth could not be reached through the 
mouth. So much relief was given by partial removal that treatment 
was intermitted for more than a year when the patient began to have 
a good deal of dyspnea and stridulous breathing. An external opera- 
tion was then done under cocaine anesthesia, the cricoid and three 
upper rings of the trachea being divided and a large quantity of soft 




Fig. 



[i 8. Subglottic Myxoma. 
( Author's specimen. ) 



pulpy material was removed with the curette and cutting forceps. 
The tracheal tube was worn for three days and at the end of the third 
week the tracheal opening had healed and the patient was discharged 
from the hospital. 

Under the microscope the growth was seen to be made up chiefly 
of mvxomatous tissue. 



ANGIOMA OF THE LARYNX. 339 

Angiomata, or vascular tumors, are very uncommon. They are 
usually single and incorporated with a vocal band, and frequently 
contain a large proportion of fibrous tissue. They have generally 
been observed in adults and with one exception only on one side of 
the larynx. They vary in color at different times, on some occasions 
being blanched, at other times vivid red in hue. In a very interesting 
case recently reported by A. J. Brady a globular angioma, the size 
of a cherry, was removed from below the vocal bands at the anterior 
commissure by means of a Heryng's curette. The patient was a boy, 
age not given, who had cough with hoarseness and bloody expectora- 
tion. Repeated attempts to remove the tumor with forceps under 
cocaine failed. No view could be obtained by Kirstein's mode of 
examination. Finally under moderate chloroform anesthesia, the 
laryngeal reflex not being abolished, the mass was removed with the 
curette in two sittings ten days apart, with complete relief of symp- 
toms. Unfortunately the diagnosis does not seem to have been con- 
firmed by the microscope and the loss of blood at the operation was 
surprisingly scanty. Most operators would consider it injudicious 
to undertake the removal of an angioma with cutting instruments, 
and an approach to a tumor of this kind seated below the vocal bands 
would be deemed preferable by an external bloodless operation. 

Enchondroma, or more properly ecchondrosis, the latter being the 
appropriate term for homologous tumors composed of cartilage, may 
spring from any of the cartilages of the larynx, is always of slow 
growth and occurs in adult life. It is usually made up of pure hya- 
line cartilage, with a possible admixture of fibrous and even bony tis- 
sue. An ecchondrosis apparently projecting toward the lumen of 
the larynx from the base of the right superior cornu of the thyroid 
was once removed by Asch with a modified Stoerk guillotine. A 
curious feature of the case was that the patient, an amateur vocalist, 
subsequently gained two notes in his upper register. 

According to Gerhardt there were on record in 1896 only ten cases 
of lipoma of the larynx, five of which were removed during life. 
Several cases have since been added to the number. Kyle states that 
the neoplasm shows a disposition to recur suggestive of a possible 
tendency toward malignant degeneration. Bosworth gives the de- 
tails of fonr cases of lipoma of the larynx as follows. One was 



340 



DISEASES OF THE NOSE AND THROAT. 



reported by Holt in a man of eighty years. It was pedunculated, 
upon the rim of the glottis, and had given rise to symptoms for twelve 
years. It was drawn into the larynx and caused fatal asphyxia. In 
a second case, reported by Jones, the lipoma, two inches in diameter, 
was removed through the mouth. In a third case, reported by Mac- 




119. Mackenzie's Laryngeal Cutting Forceps. 



leod, a pharyngotomy for a tumor as large as an orange was followed 
by fatal hemorrhage. Bruns records the case of a woman, twenty- 
five years old, who had a congenital lipoma removed piecemeal with 
the galvanocautery in fifteen sittings. 

The existence of adenoma, which is included in the list, is denied 



NEOPLASMS OF THE LARYNX. 



341 



by many authorities. F. Massei has reported two cases, but his, as 
well as several described by other observers, is far from being well 




FlG. 120. SCHROETTER-TtJRCK CANULA FORCEPS. 

authenticated. To the foregoing may be added lymphomata and 
accessory thyroid tumors, each of them so rare as to be considered 
clinical curiosities. 



342 DISEASES OF THE NOSE AND THROAT. 

The treatment of these cases of benign tumor must be guided by 
the character of the growth and its situation. Unless very extensive 
or excessively vascular the best results are obtained by endolaryngeal 
operation with forceps, except in cases of relapsing papillomata. 
Many operators give preference to instruments like the snap guillo- 
tine of Mathieu, or Dundas Grant's guarded forceps, but the instru- 
ment adapted to the majority of cases is that designed by Morell 
Mackenzie, a double curette forceps, one pattern intended to cut 
anteroposteriorly, the other transversely (Fig. 1 19) . One of the most 
convenient forceps, where for any reason Mackenzie's is found to be 
difficult of manipulation, is known as the Schroetter-Tiirck canula 
forceps (Fig. 120). Some cases can be handled by the cold- wire 
snare. A very crude way of removing neoplasms, suggested years 
ago by Voltolini, in case it is found impossible to introduce the for- 
ceps into the cavity of the larynx, consists in passing a sponge-pro- 
bang below the cords and then quickly withdrawing it in the hope 
that the growth may be caught in its meshes and torn away. It has 
a very limited application and cannot be considered a highly surgical 
procedure. Chemical caustics have been used from time to time with 
the design of destroying these growths, but the difficulty here as else- 
where is to restrict their action to the neoplasm. In at least one case 
of multiple papillomata in which removal had been attempted with 
the forceps and the growth had shown a disposition to prompt 
recurrence, an intubation tube coated with chromic acid was passed 
and allowed to remain in situ for a number of hours; on its removal 
it brought with it masses of sloughing neoplasm. Incidentally may 
be mentioned an ingenious application of intubation attributed to 
Lichtwitz. A tube made with a fenestra permits the growth to pro- 
trude into its lumen, where it may be snipped off without risk to 
the wall of the larynx. Bosworth advocates the use of chromic acid 
fused on a probe, or conveyed on a hooded porte-caustique, especially 
to destroy small fragments left by the main operation. Morell 
Mackenzie, who at one time recommended " London paste," finally 
abandoned it because it excited spasm of the glottis and inflammation 
of adjacent mucous membrane. It must be admitted that the use 
of agents of this kind in effective strength is attended by danger. 

The galvanocautery is more precise and manageable and is decid- 



TREATMENT OF LARYNGEAL GROWTHS. 343 

edly more satisfactory in its results. The use of the galvanocautery 
below the epiglottis is objected to by Lennox Browne and other ob- 
servers, but cases in my own experience lead me to believe that it is 
a most valuable agent here as elsewhere under proper precautions. 
No manipulation of the larynx of any kind should be undertaken 
without preliminary training of the patient. Unless the larynx is 
under good control there is great danger that the constrictors may 
bring in contact with the hot electrode or into the grasp of the forceps 
portions of the laryngeal structure which should not be damaged. 
Since the introduction of cocaine endolaryngeal surgery has been 
greatly facilitated. We may succeed in getting a sufficient degree 
of tolerance with a ten per cent, solution of cocaine in the larynx 
itself, and it is a good plan to paint over the pharynx and velum as 
well a solution of similar strength. In using the laryngeal forceps 
of Mackenzie the following method of technique may be adopted : 
The parts are first well sprayed with cocaine, a large laryngeal mir- 
ror held in the left hand of the operator is introduced and the forceps, 
having been warmed and anointed with vaseline, is passed over the 
epiglottis into the larynx with blades closed. If resistance is excited 
the patient is directed to take gasping respirations, or to phonate the 
falsetto " e " and thus the larynx is brought to a higher level and at 
the same time the spasm relaxes and the neoplasm becomes visible. 
Advantage of this momentary glimpse should be taken to open the 
blades and seize the growth. It sometimes happens, in cases of mul- 
tiple papilloma for example, that it is only necessary to open and 
close the blades without actually seeing the growth at the moment, 
when more or less of the neoplastic tissue will be included in their 
grasp. In the use of Mackenzie's forceps there is but little danger 
of seizing sound tissues provided the instrument be kept in the mid- 
dle line. It is not well to repeat manipulations more than two or 
three times at a sitting, yet the larynx will stand a surprising amount 
of rough handling without special objection. 

In selecting tin- method of operating, as said before, we should be 
guided by the character and situation of the neoplasm. In most cases 
Mackenzie's forceps are the best adapted for papilloma. To prevent 
recurrence we may advantageously fortify the mechanical treatment 
by certain applications to the larynx, such as some of the more power- 



344 DISEASES OF THE NOSE AND THROAT. 

ful astringents, or absolute alcohol, as successfully practiced by Dela- 
van and others. With the last mentioned agent the author has had 
more or less experience and under proper conditions is disposed to 
regard it with favor. In the case of a middle-aged lady who showed 
the larynx almost filled with papillomata so that on several occasions 
tracheotomy for relief of dyspnea seemed necessary, the tumors 
yielded to a combination of absolute alcohol with the use of the 
Mackenzie forceps, when under the forceps alone the growth would 
recur almost as fast as it could be removed. The extirpation of the 
tumors in this case was completed by T. H. Halsted. who reports 
favorably on the effect of alcohol instillations. The treatment with 
absolute alcohol is accomplished by means of a laryngeal syringe ; 
not more than six or eight drops are applied at a time, the applica- 
tion being made every second day and after the use of cocaine. In 
one case, that of a child eight years of age, the alcohol seemed to 
excite an excessive degree of irritation and had to be abandoned. It 
was resumed after the lapse of a few weeks for the reason that no 
endolaryngeal manipulation was feasible without a general anesthetic. 
The first reapplication of the alcohol was followed within twenty- 
four hours by extreme stenosis from swelling which demanded a 
rapid tracheotomy. 

Although the use of the galvanocautery in the larynx has been 
condemned several cases in my own experience have given most 
brilliant results both as regards extirpation of the tumor and restora- 
tion of vocal function. I can recall several cases of growths tucked 
under the vocal band quite beyond the reach of forceps in which extir- 
pation was effected with a slightly curved electric point with most 
satisfactory results. I would, therefore, emphatically repeat that 
with reasonable precautions and dexterity in the manipulations it is 
here, as elsewhere, a most valuable agent. 

The use of the snare in the larynx is attended with some difficulty 
in adjusting the loop. My only experience with it was in the case 
of cyst of the epiglottis already quoted which occupied the laryngeal 
face of this appendage and here the loop of the snare was readily 
engaged. Mackenzie's guarded-wheel ecraseur, or a similar instru- 
ment devised by Stoerk, is more serviceable than the unguarded 
snare in the cavity of the larynx. 



TREATMENT OF LARYNGEAL GROWTHS. 345 

The question of splitting the thyroid, or opening the trachea rarely 
arises except in children, in growths of unusual extent or dimensions, 
or in those which show a tendency to recur. My own experience 
with opening the trachea for removal of benign neoplasm is limited 
to the single case of subglottic myxoma in which I did a high tra- 
cheotomy. The operation was uneventful and its results were 
satisfactory. 

In many instances spontaneous disappearance of laryngeal growths 
has been observed to follow the functional rest imposed upon the 
larynx by a tracheotomy. Lennox Browns calls attention to the 
danger in very young subjects of damage to the lungs attendant upon 
the sudden inrush through a tracheal opening of a large volume of air 
as compared with that habitually admitted through a larynx partially 
obstructed by neoplasm. If resorption of laryngeal growths may be 
reasonably expected after a tracheotomy, it would seem to be more 
judicious to adopt this alternative rather than expose the patient to 
the risks of endolaryngeal manipulation with its uncertain results in 
the early periods of life. 

In the adult with multiple or very large neoplasms it is sometimes 
a wise precaution to open the trachea before removal of the growth 
through the mouth is attempted. In some cases portions at least of 
a tumor may be reached from below. The ingenious suggestion that 
tumors may be excised from the vocal bands by means of a fine- 
bladed knife passed through the cricothyroid membrane or through 
the thyroid cartilage at the level of the bands, as done by Rossbach 
in two cases, and guided in the proper direction by the aid of the 
laryngeal mirror held in the usual position will hardly be regarded 
as generally feasible. 

A brilliant illumination of the laryngeal cavity, a tolerant subject, 
and a firm stead}- hand on the part of the operator are indispensable 
to success in endolaryngeal surgery. The rarity of this combination 
and the comparative harmlessness of most benign neoplasms of the 
larynx may at times raise a question of the admissibility of direct 
hit rference, especially in a young and intractable patient. Under 
such circumstances Kirstein's method, by which the larynx is brought 
under direct inspection through forced depression of the tongue and 
extension of the head, mav 1).' available. Mere, ton, a general anes- 



346 DISEASES OF THE NOSE AND THROAT. 

thetic may be advantageous, although in most cases cocaine gives us 
every facility that can be desired. At a recent meeting of the Laryn- 
gological Society of London. Herbert Tilley referred to a large papil- 
loma in a child four years old which he removed with perfect ease 
under deep chloroform anesthesia, the patient being in a sitting posi- 
tion. As a rule general anesthesia, at least to a profound degree, is 
not to be recommended, or if the operator feels compelled to resort 
to it be should be prepared to open the windpipe at a moment's 
notice. 

Under the most favorable conditions the removal of a laryngeal 
neoplasm through the mouth is a procedure demanding considerable 
dexterity. A growth at the anterior commissure and especially below 
the vocal bands is not easily reached ; its structure may be so dense 
or its attachment so firm as to resist the action of a cutting forceps. 
At a first experience with forceps even in soft papillomata one is apt 
to be astonished at the toughness of the new growth and to relax the 
hold of the instrument in the fear that normal tissues may have been 
seized. In the event of failure from inaccessibility of the tumor, as 
for instance when it is concealed beneath a vocal band or in a ven- 
tricle of the larynx, or from any cause, the propriety of an external 
operation is suggested. Laryngofissure is not to be lightly advised 
both on account of the added risk involved in the operation itself, and 
especially because of the danger of permanent damage to the vocal 
function. Morell [Mackenzie's dictum that " an extralaryngeal 
method ought never to be adopted unless there be danger to life from 
suffocation or dysphagia," is probably as true to-day as it was when 
uttered, but does not include a tracheotomy done in the hope of pro- 
moting resorption of the neoplasm. The conclusion of Bruns that 
the chief objection to an external operation lies in the danger of im- 
pairment of vocal function loses a measure of its force when we take 
into account the fact that the neoplasm itself is probably responsible 
for a large part of the structural damage in the larynx. [Moreover 
in case it becomes necessary to split the thyroid in order to gain 
access to the growth a sufficiently accurate readjustment of the parts 
may be secured provided a section of the cartilage is not made com- 
pletely through its upper border. A point of far more importance 
and strongly favoring endolaryngeal methods is the fact that recur- 



TREATMENT OE LARYNGEAL GROWTHS. 347 

rences have been much more frequent after thyrotomy than after the 
former. 

Internal medication cannot be recommended with special confi- 
dence. Improvement has been claimed by some from the use of full 
doses of arsenic, and following the suggestion of Kaposi as applied 
to cutaneous warts others have had good results with Thuja occiden- 
tal-is. Small doses of protiodide or biniodide of mercury are advised 
by Watson Williams in the postoperative treatment and he also speaks 
well of the local use of a two to five per cent, solution of salicylic 
acid in absolute alcohol, as proposed by Dundas Grant. 

In comparing the relative merits of intubation, endolaryngeal oper- 
ation, thyrotomy and tracheotomy enough experience has accumu- 
lated to authorize pretty positive conclusions. Prolonged intubation, 
as pointed out by Wachenheim, is well known to be dangerous. The 
irritation caused by the tube provokes the formation of webs and 
adventitious bands and consequent stenosis. Two recent postdiph- 
theritic cases in my clinic signalize this danger. In each of these 
cases the larynx was split by Duel and after division of cicatricial 
bands beneath the vocal cords an intubation tube with a retaining arm 
or pin, like that suggested by John Rogers, was inserted. The final 
results were satisfactory, but the sojourn of the tube in these diph- 
theritic cases was even shorter than would be necessary in an average 
case of papilloma, a fact which would discredit the feasibility of intu- 
bation in the latter condition. On the other hand Robert Levy 
reports the case of a child four years old who wore a tube one hun- 
dred and eleven days almost continuously with the result of dis- 
persing a collection of laryngeal papillomata. 

In adults, and to a much less extent in children, endolaryngeal 
operations have been found satisfactory, except in certain cases of 
relapsing papillomata. Ablation may have to be done over and over 
again and the growths are reproduced with amazing rapidity. It is 
said that Bond once operated on a girl of eighteen, who in ten years 
had been relieved of papillomata about every two months. Hovell 
operated under chloroform fourteen times on a boy three and a half 
years old. Stoker records a case of a man of thirty years with the 
unparalleled record of having submitted to 220 operations since seven 
years of age. Fortunately these histories are seldom repeated, and 



348 DISEASES OF THE NOSE AND THROAT. 

in these days with tractable patients and the aid of cocaine very dif- 
ferent results may be expected. 

As to thyrotomy in •benign neoplasms of the larynx when we read 
of Walker Downie's case of six operations in one year, of Perme- 
wan's two thyrotomies, cauterization and death from asphyxia, of 
Abbe's case of four thyrotomies, cauterization and tracheotomy, and 
finally of Lendon's seventeen thyrotomies in two years followed by 
stenosis and a permanent trachea tube we are quite prepared to pro- 
nounce sentence of banishment upon this procedure. It is high time 
to discard an operation that is not only more or less hazardous, but 
gives no assurance of curing the disease for which it is performed. 

Turning to tracheotomy we find a far more encouraging showing. 
The reports of Hunter Mackenzie, Massei, Garel and many others 
establish the fact that the physiological rest given to the larynx by 
making a tracheal fistula determines a disappearance of laryngeal 
papillomata in from six weeks to five years. This occurrence has 
been observed so often that tracheotomy must be considered the 
classical mode of treating papilloma of the larynx in very young 
children, while in older subjects the tracheal opening permits a 
resort to endolaryngeal manipulations with deliberation and without 
danger. 

In all cases of development of a benign neoplasm in the larynx it 
is essential to pay attention to the condition of the upper air-track 
and in every instance make sure that the nasal cavities and the naso- 
pharynx are free from obstruction. In the opinion of many lym- 
phoid hypertrophy in the latter situation is a very frequent cause of 
neoplastic formation in the larynx. Lennox Browne holds this view, 
while Shurly declares that he has never met with a laryngeal papil- 
loma in one having at the same time adenoids in the pharyngeal 
vault. It cannot be supposed that nasal, or pharyngeal, diseases are 
the sole cause of laryngeal neoplasms, but on the ground that the 
former increase the susceptibility of the passages below their elimina- 
tion is certainly indicated. 

The after treatment in these cases of operation for laryngeal neo- 
plasm consists in the adoption of bland and soothing sprays for the 
correction of a catarrhal condition, and the enforcement of absolute 
rest. To prevent recurrence Fauvel advises insufflation of equal 



TREATMENT OF LARYNGEAL GROWTHS. 349 

parts of savin e and alum. Astringent sprays may be useful and in 
several cases sprays of alumnol have seemed to me particularly effec- 
tive. In case of violent postoperative reaction it may be necessary 
to resort to the more vigorous methods used in controlling simple 
inflammation of the larynx as already described. As a matter of 
fact acute inflammatory stenosis following an operation within the 
larynx is extremely unusual, and the less interference during con- 
valescence the better. 



CHAPTER XX. 

MALIGNANT DISEASE OF THE LARYNX. 

SARCOMA OF THE LARYNX. 

Sarcoma of the larynx is an embryonic connective tissue growth, 
and may he met with at almost any period of life. Bosworth has 
collected 47 cases of sarcoma of the larynx, the youngest being nine- 
teen, the oldest seventy-five years of age. It is therefore not a fre- 
quent lesion and there is no evidence of heredity. So far as can be 
determined there is no reason to believe that local inflammation ex- 
ercises any predisposing influence. It may remain limited to the 
larynx for a considerable time, and, only after a long period may 
extend beyond the cartilaginous walls to involve the external struc- 
tures and the lymphatic glands. In a case at present under my own 
observation a trachea tube has been worn for upwards of two years 
without marked progress of the disease. It usually occurs as a uni- 




Sarcoma of Larynx. (Chappell.) 

formly round tumor which seldom ulcerates though its surface may 
become eroded. Occasionally it is nodular and shows a tendency to 
extend downwards into the trachea. In many cases a microscopic 
examination is necessary to determine its character, but it is often 
difficult to get satisfactory sections for the purpose. In more than 
half the cases the vocal bands themselves were involved; next in 

35° 



CANCER OF THE LARYNX. 35 I 

order of frequency the ventricular bands and, in two cases, the epi- 
glottis (Fig. 121). Both round- and spindle-celled forms of sar- 
coma have been met with in the larynx, as well as lymphosarcoma, 
fibrosarcoma and myxosarcoma, primarily, or by extension from adja- 
cent parts. 

The symptoms depend upon the size and location of the tumor. 
Usually hoarseness, cough and dyspnea are present, but there may 
be no pain. There is seldom any hemorrhage of severe character 
but the sputum may be tinged with blood. The tendency to generali- 
zation is very tardy. The cervical glands are seldom involved owing 
to obliteration of the lymphatics by cell proliferation. Cachexia is 
not marked and may not develop until the laryngeal disease has ex- 
isted for a long period. 

The prognosis of sarcoma of the larynx is bad. In the majority 
of cases we are compelled to choose between a tracheotomy for the 
relief of laryngeal stenosis and complete extirpation. The latter 
must be regarded in most cases as merely postponing an inevitably 
fatal result. In a few cases of partial extirpation for very limited 
disease the operation has been successful. The mode of operating 
depends upon the size and situation of the tumor. Out of twenty- 
one cases of operation through the natural passages by the forceps, 
snare or knife collected by Bosworth, six were cured, eight were 
improved, two recurred, four were fatal, and in one there is no 
record of ultimate result. Whatever external operation is undertaken 
it is desirable to do a preliminary tracheotomy. One is often disap- 
pointed to find on splitting the larynx that the disease is much more 
extensive than it appeared in the mirror, so that what promised to 
be a partial extirpation must be converted into a complete laryngec- 
tomy. 

CARCINOMA OF THE LARYNX. 

For many years the terms sarcoma and carcinoma were used inter- 
changeably to indicate malignant disease. Confusion on this point 
has been largely dispelled by limitation of the term carcinoma to 
epithelial tissue growth. 

Cancer of the larynx may he extrinsic, intrinsic, or both combined. 
Krishaber includes in the first those lesions involving the epiglottis, 



35 2 DISEASES OF THE NOSE AND THROAT. 

the arytenoids, the aryepiglottic folds and the pyriform sinuses, and 
in the second those springing from the vocal hands, the ventricular 
bands, the ventricles and the region of the larynx below the vocal 
bands. 

Among carcinomatous lesions epithelioma largely predominates, 
although cases of medullary cancer and scirrhus have been recorded 
(Fig. 122). Its rarity is evidenced by the fact that in 11,131 cases 




Fig. 122. Epithelioma of Right Vocal Band at Anterior Commissure. 
{Schnitzler.) 

of cancer collected by Gurlt only 63 of the larynx were found. 
Hereditary influence was thought to have been discovered in about 
twenty-five per cent, of the cases, and the disease is frequently traced 
to overuse of the voice. There is usually a history of chronic laryn- 
gitis preceding the development of the neoplasm. It is essentially a 
disease of middle life and of old age, but one case on record occurring 
in a child. It generally involves a vocal band, and until a very 
advanced period of development remains intrinsic. Glandular infil- 
tration in intrinsic disease is rather a late phenomenon, the lymphatics 
in the interior of the larynx not anastomosing directly with those of 
the exterior (Fig. 123). 

The earliest symptom in the majority of cases is impairment of 
voice. It is generally progressive until complete aphonia may become 
established. Dyspnea is seldom marked at an early stage. The 
characteristic cachexia is usually observable, sometimes developing 
rather early. The patient presents a grayish-yellow complexion, his 
features become shrunken, and he has the appearance of premature 
old age. The glands in the neck sooner or later begin to show signs 



CANCER OF THE LARYNX. 353 

of infiltration, those near the cornua of the hyoid bone being first 
affected. The breath may become fetid, especially in the event of 
ulceration, more or less expectoration occurs, frequently stained with 
blood, or profuse hemorrhage may take place. Sharp pain, lancinat- 
ing in character and radiating towards the ear of the affected side is 
regarded as somewhat pathognomonic, but is not unknown in other 
conditions, and is often not a prominent symptom in cancer. 

An ulcer of the vocal band in the neighborhood of or rather in 
front of the vocal process surrounded by a livid red areola, and asso- 
ciated with more or less thickening and with decided impairment of 
mobility of the corresponding side of the larynx, occurring in a per- 
son of middle age or older, must always be looked upon with sus- 




Fig. 123. Advanced Cancerous Ulceration Left Side of Larynx. 
(Schnitder.) 

picion. It is not always possible or justifiable to remove a sufficient 
piece of the ulcer or neoplasm for microscopical examination ; a 
superficial section of the growth will often give misleading or nega- 
tive testimony, and the manipulations necessary in order to secure a 
specimen are apt to stimulate development. 

it has been a frequent experience to rely upon the microscopical 
diagnosis in doubtful cases and to make all preparations for a radical 
operation, when unexpected amelioration in the local condition took 
place and finally the lesion disappeared altogether. Several years 
ago a middle-aged man came into my service at the Manhattan Eye 
and Ear Hospital with a clinical history of epithelioma of the larynx. 
He had been under treatment at another hospital, where it was re- 



3 54 



DISEASES OF THE NOSE AND THROAT. 



ported that the microscope had pronounced the lesion to be epithe- 
lioma. A preliminary tracheotomy was done from which the patient 
made a good recovery, with the expectation of undergoing laryngec- 
tomy a week later. In the meantime he changed his mind and 
refused to submit to radical interference. He left the hospital and 
was not seen again until a year afterwards when he returned with 
voice almost completely restored and with hardly a trace of infiltra- 
tion in the larynx at the site of the supposed epithelioma. The case 




24. Kravse's Laryngeal .Ski. i. 2 and 3; Heryng's Curettes. 4 and 5; 
Landgraf's Curette, 6. 



recited is, by no means, an unusual one, and illustrates the difficult}- 
in making a positive diagnosis from the microscopic examination of 
a small fragment removed per vias natnrales. One may more 
readily appreciate this fact when recalling the various appearances 
presented by different parts of a complete section of a morbid growth. 



CANCER OF THE LARYNX. 355 

In a recent case of thyrotomy for epithelioma of the larynx all the 
diseased tissue removed was divided into two portions and one sent 
to each of two competent microscopists. Their reports were abso- 
lutely contradictory. Such an experience is no discredit to the 
microscope, but its negative testimony should be accepted with hesi- 
tation in the face of positive or even suspicious clinical signs. Many 
authorities rely confidently upon the microscope and attribute its fail- 
ure to give definite evidence to the use of an inefficient instrument in 
cutting out a piece. Moritz Schmidt, for example, insists that a 
double curette like that of Landgraf (Fig. 124) which cuts out a 
large thick segment of tissue must be used. This observer also calls 
attention to several rare forms of cancer especially difficult of recog- 
nition. While it usually appears as a well-defined tumor, it may 
have its origin in the deep tissues and give rise to a proliferating or 
vegetating condition on the surface of the mucosa closely resembling 
papilloma. Again the picture of malignant disease seated in the 
ventricle of Morgagni may simulate that of a perichondritis, or a 
cancerous mass at the posterior wall or below the cricoid may involve 
the recurrent nerve and thus its first symptoms may be those of 
laryngeal paralysis. He relies upon iodide of potash to exclude syph- 
ilis in doubtful cases and lays great stress upon the yellowish white 
color considered pathognomonic of a cancerous lesion as well as upon 
the fact that the latter seldom develops primarily at the posterior part 
of the vocal bands. Felix Semon describes a snow-white, sharply 
pointed lesion, resembling a papilloma, but less bulbous and rounded, 
as " extremely suggestive of malignant disease." The same authority 
gives interesting details of a case seen by himself and several other 
eminent surgeons in which the clinical history of cancer was almost 
unequivocal. A tracheotomy preparatory to a complete extirpation 
disclosed a number of apparently infected glands and the major oper- 
ation was abandoned. A year later the patient reappeared still wear- 
ing his trachea tube but with no trace of glandular infiltration and no 
laryngeal stenosis. It seemed that in the meantime he had been tak- 
ing ' 'lay's mixture of Chian turpentine, a preparation that once had 
quite a reputation as a specific in cancer. Semon attaches no impor- 
tance to the use of this article, but holds the view thai the cast' was 
really one <>t~ syphilitic perichondritis and that the glandular swelling 



356 DISEASES OF THE NOSE AND THROAT. 

was purely inflammatory. Iodide of potassium was given without 
result when the case was first seen and unfortunately the glands re- 
moved at the operation were not examined microscopically, so that 
the nature of the lesion remains in more or less doubt. 

The diagnosis of carcinoma of the larynx in its early stage is ex- 
tremely important, since it is only at this period that we may hope 
to do anything in a surgical way. The tumor may be seated at a 
point where a radical operation would certainly include it all. Hence 
if the parts can be exposed in the early period of development we 
shall succeed in prolonging life if not in ridding the patient perma- 
nently of his disease. The propriety of attempting to exclude certain 
other diseases by tentative treatment always suggests itself. The 
tuberculin test may be of service as regards tuberculosis. In using 
iodide of potash in order to eliminate syphilis attention should be 
drawn to the fact that very large doses must be given and that ameli- 
oration in many ulcerative conditions occurs at the first administra- 
tion of the drug, whereas no impression whatever is made by it upon 
that rare form of fibroid degeneration sometimes occurring in old 
syphilis. Moreover complications may arise from the coexistence of 
syphilis or tuberculosis with cancer. Under such circumstances a 
syphilitic history or the discovery of tubercle bacilli may divert us 
from the more serious lesion. Transillumination and the Roentgen 
ray have been used to demonstrate an area of infiltration. The re- 
sults they give are more curious than valuable, since by the time an 
infiltration has become extensive and dense enough to give decided 
reaction other evidences are sufficiently pronounced. 

The prognosis in cancer of the larynx is gloomy, and the results 
of operation are worse the longer the delay. 

Treatment may be palliative or radical. In case radical interfer- 
ence is not feasible or be declined, we are compelled to meet the 
various symptoms as they arise. So far as the patient is concerned 
the most distressing symptom in the final stages if not at the outset 
is pain. As a last resort we have morphine in some form, either 
hypodermically or by the mouth, but it is well to try first the effect 
of various local anesthetics. Much temporary relief may be obtained 
from applications of morphine, 4 grains, tannin and carbolic acid, 
each 30 grains, in half an ounce each of glycerin and water (Ingals). 



CANCER OF THE LARYNX. 357 

A solution of carbolic acid, i J / 2 dr., tinct. iodine 4 dr., and glycerin 
2 dr., has been found very serviceable in mitigating the pain of an 
ulcerative lesion in malignant disease as well as in syphilis. A con- 
siderable degree of comfort may be given in the early stages by spray- 
ing with cocaine in ten per cent, solution, or stronger, or with a ten 
per cent, solution of nirvanin, a recent succedaneum of cocaine, which 
is found to be quite equal in anesthetic power and is much less 
toxic. The latter does not act unless there is a lesion of the mucous 
membrane or it is injected into the tissues. It has the advantage 
over cocaine that its solution may be sterilized without impairment 
by boiling. The pain of epithelioma may be mitigated by insuf- 
flating the ulcer, after cleansing with an alkaline wash, with ortho- 
form — new. Several hours' respite from pain may be secured by 
thorough application of the powder. If applied after cocainization a 
certain quantity is likely to be retained in contact with the ulcerated 
surface. 

Liegeois reports good results from the internal administration of 
Thuja occid entails, as well as from local application of the same drug. 
In a case of recurrent epithelioma of the larynx, after an operation 
by Kraus, the patient was given Fowler's solution of arsenic. Dur- 
ing this course three pieces of the tumor were coughed up and death 
finally occurred from intercurrent pneumonia five and a half years 
after the tracheotomy, the neoplasm having apparently disappeared. 
The favorable reports of such treatment might be thought to throw 
suspicion upon the diagnosis. 

The surgical treatment of cancer of the larynx may be conducted 
through the mouth or by external operation. 

The development of laryngology has naturally aroused great hopes 
for the endolaryngeal method, which are likely to be revived by a 
recent report by B. Fraenkel of nine cases, five of which were suc- 
cessful. In one case in which a neoplasm was extirpated with the 
galvanocautery loop five recurrences took place. In one the cervical 
glands had to be removed by repeated external operations. The im- 
portance of constant watchfulness is insisted upon, so that the time 
for an external operation, should it prove to be imperative and prac- 
ticable, may not be permitted to pass. Allowance must be made for 
the unusual diagnostic acumen and manual dexterity of this operator. 



358 DISEASES OF THE NOSE AND THROAT. 

Similar cases have been reported by Mermod and Kraus, the latter 
observer very properly limiting the endolaryngeal operation to poly- 
poid or circumscribed cancers. One of the firmest advocates of 
endolaryngeal extirpation is Jurasz, who limits the method to the first 
stage when functional disturbance is slight and the disease is local 
and circumscribed. He thinks well of the electric cautery, but pre- 
fer.- excision by means of a punch forceps of his own design. From 
a recent thorough review of thi- subject Gouguenheim and Lombard 
conclude that the endolaryngeal route is not available for cancers 
even of limited extent. The following arguments in its favor, first 
that many intrinsic cancers tend to remain circumscribed indefinitely, 
second, that in old people no external operation of magnitude is to 
be considered, and. finally that some pedunculated epitheliomata 
threatening asphyxia demand rapid interference are not admitted to 
In convincing. They recognize that a tracheotomy often seems to 
retard the growth of a neoplasm and express decided preference for 
partial laryngectomy in operable cases. It would be unfortunate if 
the results first quoted should unduly stimulate the zeal of surgeons 
in this direction, lest improper cases be selected for endolaryngeal 
operation and thus valuable time be lost. Amelioration of the local 
condition has frequently been observed to follow rest of the larynx 
secured by tracheotomy. The majority of cases apply for advice so 
late that relief of symptoms by the use of local applications and, if 
necessary, the introduction of the trachea tube, comprise all that we 
are justified in doing. In a small proportion in which an early diag- 
nosis may be positive and in which the disease is known to be dis- 
tinctly circumscribed fissure of the larynx with thorough removal of 
the soft parts involved and beyond, will offer some hope. The ob- 
jects we should have in view are in the first instance to eradicate the 
disease, if possible; and if that is not feasible to add to the comfort 
and prolong the life of the patient. The latter course may seem less 
humane than a well-directed euthanasia, yet public sentiment does 
not permit us to treat the human subject with the consideration we 
apply to the lower animals under similar circumstances. It may be 
laid down as a general law that cases in which the disease is progres- 
sive and has invaded the larynx so far as to necessitate complete re- 
moval of that organ with its cartilages and the adjacent -lands, sh< >uld 



CANCER OF THE LARYNX. 359 

not be subjected to radical interference. The probability is very 
strong that the disease has by this time crept along some lymphatic 
channel beyond the reach of the eye where it will escape the knife, 
and become a focus for recurrence within a very short time. Statis- 
tics show, up to the present time, that nearly ninety per cent, of 
operative cases are fatal, either immediately or from recurrence — by 
no means a reassuring outlook. With increased accuracy in diag- 
nosis and improvement in operative technique the results may become 
more favorable. The best individual statistics hitherto published are 
those furnished by Gluck, of Berlin, fourteen successful partial laryn- 
gectomies and only three deaths in a series of thirty-five complete 
excisions. He attributes his success to prevention of aspiration 
pneumonia by a preliminary resection of the trachea, the air-track 
being thus absolutely isolated from the site of operation. In view 
of the fact that the laryngeal tissues are enclosed in cartilaginous 
walls, through which no lymphatics pass, the chances of recurrence 
after removal of cancer of the larynx strictly intrinsic are less than in 
other situations. There is a marked difference between intrinsic and 
extrinsic cancers in the greater tendency of the latter to involve the 
cartilage as well as the lymphatics, a point which has a very important 
bearing on the prognosis and the mode of operating. For the reason 
suggested above Watson Cheyne and other authorities regard the 
glandular trouble as not the most serious operative complication. 
The septic element is by far the most important factor as regards 
mortality from the operation. A careful observance of all precau- 
tions and a judicious selection of time and method of operating will 
surely reduce the danger from this source. Desirable conditions as 
to the patient are enumerated by Delavan as follows : He should not 
be too old, he should be possessed of good vitality, he should suffer 
from no physical defect that may retard recovery, and his tempera- 
ment, intelligence and surroundings should be favorable to a com- 
fortable existence after operation. The personal equation is perhaps 
too little considered. It is a notorious fact that certain individuals 
go through the most formidable surgical procedures with equanimity 
while others collapse under a comparatively trifling ordeal. To some 
the loss of an important organ with deprivation of vocal function is 
intolerable. Confirmed melancholia and suicidal tendency have been 



360 DISEASES OE THE NOSE AND THROAT. 

known many times to develop after complete laryngectomy. The 
various artificial devices for supplanting the human larynx, while 
most ingenious and interesting, are very poor imitations of the orig- 
inal mechanism, and to many would seem impossible. The kind of 
voice cultivated by several subjects whose larynx had been removed 
for cancer in such a way that communication between the lungs and 
the pharynx was entirely closed cannot be considered very satisfac- 
tory. In discussing operative interference in a given case the patient 
should be taken into our confidence and the ultimate decision left in 
part at least to him after a fair presentation of the question. 

The opinion is held by some authorities that the rule applicable to 
malignant disease in general should be rigidly enforced as regards 
cancer of the larynx, that is, the extirpation should include a wide 
area of adjacent healthy tissue and every suspicious lymph gland and 
channel. Unfortunately, perhaps, the average American will hardly 
bring himself to submit to the mutilation involved in the application 
of this principle, especially since even thus absolute certainty of im- 
munity cannot be ensured. He will prefer rather to accept the com- 
fort afforded by anodynes and a tracheotomy, when compelled to face 
that necessity, and in the meantime get what pleasure he may out of 
life. In a recent eloquent and forceful plea for early naked eye diag- 
nosis of cancer of the larynx and complete laryngectomy a distin- 
guished authority, J. X. Mackenzie, has made the admission that there 
is no single unequivocal laryngoscopic sign of cancer. A conclusion 
must be reached from a study of the congeries of symptoms, local and 
general, subjective and objective. Excision of a piece of suspected 
tissue for microscopic purposes, except as a very final resort, is ob- 
jectionable because ( 1 ) it opens the way to autoinfection and metas- 
tasis, (2) it stimulates the growth of the cancer, and finally (3) it is 
often inconclusive, misleading, and is sometimes practically impos- 
sible. It is not an uncommon experience for a laryngeal neoplasm 
previously benign in appearance and clinical history to suddenly 
undergo absolute change of behavior after attempts at removal for 
curative or diagnostic purposes. As a general rule growths of the 
larynx of doubtful nature, especially in middle-aged or older persons, 
should not be tampered with unless we are prepared to meet this con- 
tingency. It is not my purpose to discuss the various methods of 



CANCER OF THE LARYNX. 36 1 

performing excision of the larynx. Our patients are entitled to all 
the art and skill bestowed by constant familiarity with the details of 
surgical technique. Hence it becomes our duty to secure the counsel 
and assistance of the general surgeon in these cases. It remains the 
business of the specialist to cultivate the utmost proficiency in identi- 
fying the early symptoms of laryngeal cancer before the disease has 
become inoperable. The proposition made several years ago by H. 
T. Butlin to do an explorative laryngofissure in every case of tumor 
of the larynx suspected of malignancy has not met with universal 
favor. Should it be accepted as a justifiable diagnostic resource it 
would seem wise never to undertake it without a distinct understand- 
ing that the operator be authorized to proceed to any extent indicated 
by the character of the neoplasm thus exposed. In a series of thir- 
teen thyrotomies recently reported there were three deaths directly 
attributable to the operation. The opinion is expressed by Semon 
that while it is not free from risk the dangers of splitting the thyroid 
are almost always avoidable. The fact has often been noted that the 
disease is invariably found to be more extensive than it appeared to 
be in the laryngeal mirror. Therefore the wisest policy seems to be 
to place our reliance on other means of diagnosis and resort to a 
thyrotomy only when we are prepared to go to the full length of 
surgical interference. 

In comparing thyrotomy as an operative procedure with other 
methods hitherto practiced it must be admitted that much may be said 
in its favor. The technique of the operation as perfected by Butlin, 
Semon and others gives a much more favorable showing as regards 
operative mortality. Yet even in the most skillful hands fatalities 
occur, and even the preliminary tracheotomy, considered essential, is 
neither so easy, especially when the trachea is entered below the isth- 
mus, nor so safe as is often represented. 

In a recent review of the statistics of thyrotomy by Ernest Wag- 
gett, based upon the experience of the surgeons just mentioned, the 
superiority of laryngofissure over total extirpation in the three par- 
ticulars of (i) preservation of function, (2) death rate from the 
operation, and (3) exemption from recurrence seems to be clearly 
established. He comments adversely on Mackenzie's demand for 
extensive operation in malignant disease of the larynx both on ac- 



362 DISEASES OF THE NOSE AND THROAT. 

count of the deplorable state in which the patient is left and chiefly 
because it offers no security against recurrence. Sendziak, who has 
investigated this subject most carefully, has tabulated 640 cases oper- 
ated upon by the endolaryngeal method, by thyrotomy, by partial 
and by complete excision, lie regards operative interference with 
favor and believes thyrotom) to be safest and most promising as to 
cure, that term implying no recurrence three years after operation. 
All the testimony bearing on the question tends to enforce the impor- 
tance of early identification of malignant disease and seems to justify 
the conclusion already expressed that conditions so extreme as to 
require a complete laryngectomy render a given case inoperable. 

Many malignant tumors of the larynx develop slowly, as declared 
by Ruault, seven or eight years passing without very pronounced 
change. With this fact in mind and viewing the disappointing re- 
sults of radical intervention, it may be worth while to consider meas- 
ures for controlling the nutrition of the affected region, either by 
such a procedure as ligation of the arteries supplying the larynx after 
the method of Dawbarn, or by the frequent application of agents like 
adrenal extract whose ischemic power is well established. 

It remains to be seen whether phototherapy, which has been tried 
with a promise of success in tuberculosis as well as in superficial forms 
of external cancer, is capable of exerting an influence upon the less 
accessible and possibly more resistant type of malignant disease as 
developed in the larynx. Some of the cases reported up to the 
present time showed more or less improvement and one definite cure 
has been recorded (Scheppegrell ). Unfortunately that last men- 
tioned was not confirmed by the microscope, yet the accuracy of the 
diagnosis based on the clinical history is confidently affirmed. Dela- 
van asserts that not a single authentic case of cure can be found, but 
he believes in the extraordinary possibilities of the method and that 
in every cast- of reputed, cure sufficient time should be allowed to 
elapse to prove its permanency. It seems lair to conclude that all 
cases manifestly inoperable should be allowed the chance it offers. 



CHAPTER XXI. 



TUBERCULOSIS OF THE LARYNX. 



Tuberculosis may attack the larynx primarily or secondarily ; in the 
former case, the process is usually acute ; in the latter, chronic. 

Primary tuberculosis of the larynx is believed by some authorities 
to be not very uncommon and is thought to have certain distinguish- 
ing characteristics. According to Bernheim, in the beginning mil- 
iary granulations may be seen in the arytenoid region accompanied 
by a general laryngitis of mild grade. Finally ulcers form which 
take on a vegetating or papillomatous character. Tubercle bacilli 
may be found in the sputum or in scrapings of the ulcers, sometimes 
only after careful and prolonged search. Twenty-nine cases of pri- 
mary tuberculosis of the larynx have been reported by Aronsohn, 
three of which are authentic, in seven the coincident pulmonary 
lesion was limited and believed to be secondary, while in nineteen 
the diagnosis of primary laryngeal disease was based solely on clin- 
ical signs, which of course cannot be accepted as conclusive. Oppor- 
tunities to verify a diagnosis are rare because death seldom occurs 
until the presence of the disease in other situations is manifest. Early 
identification is obviously important, in order by suitable local treat- 
ment, diet and hygiene to prevent the disease from becoming general- 
ized. Some authorities, also, recognize a pretubercular or prebacil- 
lary state in which no positive signs of tuberculosis can be discovered 
either in the lungs or larynx, which demands attention and in which 
much may be done to ward oft" the more serious lesions of the actual 
disease. At this time the larynx is free from ulceration and infiltra- 
tion, but, as pointed out by Ringk, may be anemic or hyperemic. 
The former is usually characteristic of a chronic, the latter of an 
acute process. In the former case irritating applications should be 
avoided, lest edema or erosions be induced. In the latter astringents 
are of value and measures should he taken to correct a general 
catarrhal condition. Weakness of the voice amounting al times to 
partial aphonia, subnormal morning temperature with more or less 

}6 3 



364 DISEASES OF THE NOSE AND THROAT. 

rise the latter part of the clay, associated with anemia of the larynx 
or possibly a circumscribed hyperemia of one vocal band, should 
always excite apprehension, even though cough may be moderate, 
sputa scanty, and tubercle bacilli not found. The depth and limita- 
tion of an incipient pulmonary lesion may prevent its detection by 
physical signs, and admitting their absence we may not be justified in 
pronouncing such a case one of tuberculosis. We are urged, how- 
ever, to take steps to bring about an improvement in the local condi- 
tions which will tend to diminish a susceptibility to tubercular infec- 
tion of the larynx. This especially refers to use of the voice and to 
intimate association with others known to be infected. The family 
history and the question of heredity are concerned so far as these 
factors may be capable of impairing constitutional vigor and power 
of resistance. In accordance with modern views we are not author- 
ized in condemning an individual because his ancestors had tubercu- 
losis. An inherited tendency, if such a thing exists, may almost 
surely be corrected in a climate which permits continual life in the 
open air. Unfortunately this is not always practicable and often- 
times the prescribed treatment and regime must be carried out under 
most unfavorable circumstances. 

As to etiology, any condition, local or general, which favors the 
growth of the tubercle bacillus, may invite the disease to the larynx. 
A condition of low vitality combined with the existence of a catarrhal 
state of the mucous membrane affords predisposition. We find 
laryngeal tuberculosis more frequently in the male sex than in the 
female for the reason that the occupations of men expose them more 
generally to the exciting causes. It is most likely to develop between 
the ages of twenty and thirty years. 

Subjects of tubercular laryngitis are liable to intercurrent attacks 
of simple inflammation, and are prone to exhibit temporary improve- 
ment in summer, in mild weather and under change of climate. The 
frequency of the disease is very startling. 1 teinze, of Leipsic, reports 
4,486 autopsies, in i,_»26 of which tuberculosis was found; of the 
latter 51.3 per cent, showed laryngeal lesions, more than one half 
being ulcerative, a proportion confirmed by the statistics of the 
Brompton Consumption Hospital but nearly twice as large as that 
admitted by many investigators. The mode of invasion of the larynx 



TUBERCULOSIS OF THE LARYNX. 365 

is either by direct infection through the inspired air or by the expec- 
torated sputum, or indirectly by conveyance of bacilli from tubercular 
foci in the lungs through the blood current or the lymph channels. 
The latter is doubtless more frequent. If the contrary were true 
tubercular laryngitis would be much less rare than it is. Various 
theories have been propounded to explain the comparative immunity 
of the larynx. It is said that the bacillus of Koch, which is supposed 
to be the essential element in infection, requires not only suitable soil 
but a quiet resting place for its development, and that abrasions of 
the mucous membrane of the larynx, which might permit the en- 
trance of the bacillus, are promptly protected against it by the forma- 
tion of exudate or granulations. E. L. Shurly, who expresses skep- 
ticism as to the importance of the part played by bacilli in infection, 
combats the foregoing views and calls attention to the fact that while 
some parts of the larynx are almost never at rest the ventricles are 
certainly sufficiently quiescent and secluded as regions for the lodg- 
ment and cultivation of germs. There is no reason to believe that 
the laryngeal mucosa differs from similar tissue elsewhere in its 
defensive power. As to the bacillus, while it has been proved to 
retain its vitality in a bronchial gland in a state of latency for twenty 
years, it has also been demonstrated that some tubercular lesions con- 
tain no bacilli. This of course must be taken for what it is worth as 
negative testimony, and is in consonance with Cohen's suggestion 
that certain elements capable of conversion into tubercle bacilli exist 
normally in the tissues. The majority of observers will probably 
agree with Delafield and Prudden that the effect of the bacilli is 
governed by their number and virulence, by the nature of the tissue 
in or upon which they rest, and by the vulnerability of the individual. 
Although some authorities deny that mouth breathing is a factor in 
tubercular infection it is believed that the importance of nasal stenosis 
as favoring derangements of any kind in the lower air-track should 
not be underestimated. Yet it must be considered injudicious to 
undertake operative measures for the correction of nasal atresia in 
a tubercular subject unless it is quite certain that his vitality is 
capable of withstanding the additional drain. 

The pathological changes characteristic of laryngeal tuberculosis 
consist of cellular infiltration and edematous phenomena, together 



366 DISEASES OF THE NOSE AND THROAT. 

with tubercle bacilli, especially in the miliary form associated with 
ulceration or caseation. In the early stage the capillaries are en- 
gorged, the tissues are crowded with leucocytes and small round 
cells, the glands are distended with serum and cells and finally 
become obliterated. Nodules of granulation tissue appear and feeble 
attempts at organization are seen, but finally necrosis, softening and 
ulceration take place. The breaking down process begins in the 
deeper layers, thence extending to the surface of the mucous mem- 
brane, or to the perichondrium, in the latter case sometimes involving 
the cartilage itself. Tubercular foci are identical with those found 
in other situations, consisting of scattered masses of large epithelioid 
cells, usually enclosing one or more giant cells, embedded in a zone 
cf granulation tissue and surrounded by loose irregular small cells 
of infiltration tissue. In localized disease a compact wall of cells and 
fibrous connective tissue surrounds the morbid deposit. The tubercle 
is not vascular and bacilli may be found both within and without the 
cells. The secretion of a tubercular ulcer is found to contain disin- 
tegrated epithelial cells, mucus, a small amount of pus, and generally 
tubercle bacilli. Free pus formation is not a usual feature. 

The earliest symptoms of laryngeal tuberculosis relate chiefly to 
the voice. There is more or less huskiness, the voice becomes low 
pitched, and attempts at loud phonation may result in diphonia, or 
double voice. The impediment to breathing is not, at the onset, at 
all marked although respiration may be labored and more or less 
stridulous. The amount of sputa is not excessive until the lungs 
become involved to a considerable extent. There is little or no 
trouble in swallowing until the late stages of the disease when deglu- 
tition may become not only difficult but painful. The impediment to 
swallowing may be due either to simple inflammatory swelling espe- 
cially of the posterior laryngeal wall, to involvement of the peri- 
chondrium or cartilages themselves, or to more or less extensive ulcer- 
ation. In the early stages there is little or no pain, although the 
patient may complain of a sensation as of a foreign body, or simply 
a feeling of uneasiness or dryness. There may he more or less exter- 
nal tenderness on pressure over the thyroid cartilage. One of the 
most distressing and persistent symptoms even at the beginning is 
rough. The cough of laryngeal tuberculosis is most marked in the 



TUBERCULOSIS OF THE LARYNX. 367 

morning and when the patient first assumes the recumbent position 
at night. 

The diagnosis of laryngeal tuberculosis in typical cases is free from 
difficulty. There is hardly any laryngeal disease, however, which 
presents so many variations from what we are accustomed to call the 
typical form. In the early stages of the disease, a feature by no 
means invariable, which strikes us with most force in the laryngeal 
mirror is the pallor of the mucous membrane. This is especially 
marked in the chronic form and is not proportionate to the degree 
of general anemia. Infiltration and tumefaction are observed particu- 
larly in the interarytenoid space and of the ary-epiglottic folds. The 
normal prominences of the arytenoids are effaced by a pyriform swell- 
ing involving both sides of the larynx and usually quite symmetrical. 
They assume the so-called " club-shaped " contour (Fig. 125). The 




Fig. 125. Tuberculosis of Larynx. Clubbing of Arytenoids and Papillary 
Excrescences at Posterior Commissure. (Schnitsler.) 

epiglottis may be infiltrated and swollen, or " turban-shaped." In 
exceptional cases the infiltration of the larynx is unilateral, and the 
uncertainty of diagnosis is much increased (Fig. 126). The mucous 
membrane has an edematous, soggy look. The movements of the 
arytenoids are interfered with by infiltration of the muscles or pos- 
sibly by an inflamed cricoarytenoid joint. The importance of the 
latter has been especially insisted upon by W. Fowler, who in upwards 
of fifty autopsies found implication and more or less disorganization 
of the joint in every instance. Aphonia may be due to this cause, or 
simply to a general weakness of the intrinsic muscles of the larynx, 



3 68 



DISEASES OF THE NOSE AND THROAT. 



or to an intercurrent laryngitis. When there is apparent unilateral 
paresis it is generally observed upon the right side and is due to 
involvement of the right recurrent nerve by pleuritic adhesions, con- 
solidation of the right apex, or pressure from bronchial glands. 
Ulceration is met with in late stagas and is due to a breaking down of 




Fig. 126. Tubercular Ulcer with Extreme Swelling of Left Arytenoid. 
( Lennox Browne. ) 

small tuberculous foci which coalesce, giving the ulcer a characteris- 
tic worm-eaten or nibbled margin (Fig. 127). Superficial erosions 
resembling aphtha? may occur. Necrosis and caries are not uncom- 
mon and may involve almost any of the cartilages. Among the un- 



Fu 




Ti BER( ill SIS 01 

(Lennc 



RATIVE Stage. 



visual forms of tubercular development within the larynx are what 
have been designated granulomata, papillary excrescences at the pos- 
terior commissure, and distinct tumors or nodules, usually rounded 



TUBERCULOSIS OF THE LARYNX. 369 

and smooth and covered by mucous membrane not differing from 
that of other parts of the larynx (Fig. 128). These tumors seldom 
soften and ulcerate, and are most frequently seen on the lateral walls 
of the larynx, or in the trachea just below the vocal bands. Wart- 
like growths between the arytenoids are occasionally seen in syphilis 
and in chronic laryngitis, but point to incipient tuberculosis when 



Fig. 128. Tubercular Tumor of Larynx. (Rice.) 

associated with pallor of the mucous membrane or suspicious pul- 
monary signs. Granular hyperplasia at times reach a considerable 
volume, especially when springing from the margins or base of an 
extensive ulceration. They usually shrink before offering any seri- 
ous impediment to breathing. The contrary was true in a case once 
reported by the author, that of a boy twelve years old, in whom 
laryngeal stenosis from tubercular granulomata demanded an intu- 




Fig. 129. Tubercular Ulceration at Posterior Commissure and Vocal 
Processes. (Schuitclcr.) 

bation and finally a tracheotomy, death occurring a few weeks later 
from general tuberculosis. The youth of this patient and the pre- 
sumption that it is an instance of primary laryngeal tuberculosis 
give the case especial interest (Fig. 129). 

The symptoms of general tuberculosis, anorexia, emaciation, hec- 
tic, rapid pulse, night sweats, cough with expectoration, and possibly 
24 



370 DISEASES OF THE XOSE AND THROAT. 

hemoptysis are marked in proportion to the degree and activity of 
pulmonary involvement. Nutrition may be interfered with by a very 
extensive laryngeal lesion before signs of pulmonary disease are in 
evidence. 

A differential diagnosis must be made from cancer and syphilis. 
Confusion is not likely to arise from other sources. In the former 
there is sooner or later marked cachexia, more or less constant pain, 
frequently shooting toward the ear of the affected side, aggravated 
by swallowing and more intense when fluids are taken. The lesion 
itself begins as a neoplasm, later becoming a deep, ragged ulcer coated 
with grumous, fetid secretion and surrounded by a livid or purplish 
areola. The mobility of that side of the larynx affected is impaired 
early by the infiltration. The voice is lost and stenosis may be ex- 
treme. In syphilis the voice is hoarse and low-pitched, but complete 
aphonia is rare until late destructive ulceration or cicatricial contrac- 
tion occurs. The latter condition may also cause excessive dyspnea. 
The ulcer itself is comparatively free from pain, and the constitu- 
tional symptoms are as a rule unmistakable. The lesion is usually 
clean cut with raised indurated edges and covered with necrotic 
detritus. Characteristic scars in the pharynx or elsewhere, or traces 
of the disease at some other part of the body, even in the absence of 
a history, or of active symptoms, will usually solve the problem. The 
greatest perplexity arises in connection with latent syphilis, or " syph- 
ilis ignore," and in cases of mixed infection. An example of the 
latter in my own experience was betrayed by typical ulceration of 
the fauces which healed under mixed treatment leaving characteristic 
scars. The patient had already been sent to a mild climate for tuber- 
culosis, the latter diagnosis having been based on pulmonary and 
general symptoms confirmed by tubercle bacilli in the sputum. Lu- 
pus, glanders and leprosy, all very rare diseases, may simulate the 
local appearances of tuberculosis, but the history of these is usually 
conclusive. In exceptional anomalous cases the diagnosis must 
be held in abeyance almost indefinitely. This applies particu- 
larly to primary tuberculosis of the larynx. Pulmonary disease may 
be so deep-seated, or limited, as to give no signs, and. moreover, 
infection may take place in the larynx and may remain localized in 
that organ for a considerable time. In very rare cases of chronic 



TUBERCULOSIS OF THE LARYNX. 37 I 

laryngitis the hypertrophy of the mucous membrane may be so ex- 
treme as to resemble a tubercular infiltration, but such conditions 
usually occur in those whose occupation and habits account for the 
extraordinary thickening. 

In the laryngeal mirror the characteristic appearances of a tuber- 
cular larynx are the semi-solid, edematous infiltrations or the 
" worm-eaten " ulceration involving the epiglottis, the arytenoids, or 
the aryepiglottic folds. Usually the lesions are symmetrical or bilat- 
eral. The ulcer of tuberculosis is covered with pale granulations, 
its floor is not deeply excavated, and its edges are irregular and nib- 
bled, owing to the confluence of small marginal ulcerations and break- 
ing down of minute tubercular foci. There is seldom an areola as in 
cancer and syphilis ; on the contrary, the surrounding parts are pale. 

The prognosis in tubercular laryngitis is admittedly bad, but by 
no means hopeless. Life may be threatened by suffocation, by inani- 
tion, or death may occur from hemorrhage, yet the laryngeal 
lesion itself is seldom fatal except as it may interfere with the 
patient's nutrition through inability to swallow. Serious hemor- 
rhage, unless of pulmonary origin, in laryngeal tuberculosis is ex- 
tremely rare, and sudden stenosis from edema or swelling equally so. 

Treatment.— The fact must be recognized that in most cases the 
laryngeal lesion is simply one phenomenon in a constitutional disease. 
We are called upon to treat, however, not only the general condition 
but certain local lesions which interfere with the patient's comfort 
and tend to shorten his life. A prominent subjective symptom is the 
persistent cough. The neurotic element is, in some cases, very 
marked and may be overcome in a measure by the use of sedatives, 
such as the bromide of potassium or sodium which may be given in 
full doses, or small doses frequently repeated. It is important to 
protect the patient from irritating atmospheres as far as possible, to 
keep him in a uniform temperature, and to insist upon rest of the 
larynx and, when dysphagia is present, to provide nutriment easily 
swallowed and highly concentrated. It is found that large mouth- 
fuls of food or drink may be swallowed with greater ease or less dis- 
comfort than small quantities. When odynphagia is very marked 
what is known as Wolfenden's method of feeding may be resorted to 
with success. The patient is directed to lie prone upon the face with 



$ J 2 DISEASES OF THE XOSE AND THROAT. 

his head over the end of a lounge and is made to take nourishment 
in fluid form through a tube. It is a curious fact that some patients 
who can swallow absolutely nothing without pain in the ordinary posi- 
tion are able to do so with ease when in this attitude. Hovell recom- 
mends a simple and but little known method of relieving pain in swal- 
lowing by means of firm pressure with the hands of one standing 
behind the patient. The pressure should be applied parallel with the 
posterior border of the ramus of the lower jaw, the fingers being 
directed upwards, and gives greater relief the more firmly it is ex- 
erted. 

There seems to be a difference of opinion about the effect of alti- 
tude in laryngeal tuberculosis. It is very certain that some patients 
do well, while others do not thrive, at high altitudes. As a rule, if 
heart complications or weakness exist, and in acute tuberculosis, it is 
best to keep the patient near the sea level. It has been observed that 
tubercular cases giving a history of long-standing antecedent catarrh 
which has advanced to atrophy do badly at high altitudes. 

The usual general medication of supportive character is to be 
adopted. Cod-liver oil, or jecorol, hypophosphites alone or combined 
with oil, and in some cases the glycerophosphates of lime or soda 
will be found useful. Shurly warmly advocates iodine internally. 
He claims the best results when it is combined with some proteid, and 
is accustomed to give it in bouillon or milk. Arsenic, creosote, 
guaiacol and many other drugs are employed with possible benefit. 
Tuberculin, except as a diagnostic test, has been practically aband- 
oned. It is impossible in a limited space to review all the internal 
remedies recommended at various times, and were all to be enumer- 
ated we should still be forced to the conclusion that at present a cure 
for tuberculosis does not exist. Our chief reliance in restricting and 
suppressing the disease must be upon a more faithful observance of 
hygienic laws in general and more stringent precautions as to those 
already infected. 

Fatty foods if assimilated seem to be of service. An excellent and 
somewhat palatable preparation of " mixed fats " (Russell emulsion) 
i- generally well borne. Careful nutrition is important. Tubercu- 
lous patients should be encouraged to eat rather more than they seem 
to desire. The appetite may be stimulated with bitter tonics or alco- 



TUBERCULOSIS OF THE LARYNX. 373 

hoi, unless the latter proves too irritating. In many cases alcohol 
seems to take the place of food and large quantities are consumed with 
apparent benefit. A life in the open air and sunshine should be 
urged. Avoidance of bodily fatigue and mental worry must be en- 
sured as far as possible. 

The local treatment of tubercular laryngitis is most important and 
in some degree encouraging. Soothing inhalations, such as com- 
pound tincture of benzoin, oil of pine, eucalyptus and menthol, agents 
whose object is two-fold, are indicated. In the first place they reduce 
hyperemia and irritation ; and, in the second place, they correct the 
tendency to the formation of viscid secretions in the cavity of the 
larynx, the expulsion of which is accomplished with great difficulty. 
The most gratifying results in these respects will be found in connec- 
tion with the use of menthol. Whatever view may be held in regard 
to its antiseptic properties there seems to be no question that it re- 
duces congestion of the mucosa and renders the secretions more fluid 
and less tenacious. It may be applied directly to the diseased surface 
drop by drop with a laryngeal syringe in fifteen to twenty per cent, 
solution, or in much less strength with a nebulizer or fine spray. At 
first it is quite pungent and even painful without cocaine, but in a few 
moments a cool soothing sensation supervenes which is rather agree- 
able to most people. Menthol is soluble in olive oil or fluid albolene 
and may be used in the larynx either hot or at ordinary temperature, 
whichever seems more grateful to the patient. Weak solutions may 
be used at short intervals so as to keep up a continuous effect and 
give as good results as those of greater strength. 

The use of iodoform, either by insufflation or in ethereal solution, 
or in an oily emulsion has been much in vogue and still is highly 
recommended. It is believed that equally effective and less disagree- 
able medicaments may be selected. It is more or less valuable in the 
ulcerative stage combined with morphine and an astringent, as fol- 
lows : morphine, 10 gr., tannic acid, 2 dr., iodoform, 6 dr. (Bos- 
worth). This may be insufflated daily with an ordinary powder 
blower, care being taken not to use an excessive amount of the pow- 
der. Formalin as a pigment in one to ten per cent, solution is highly 
recommended by Lake, either alone, or preferably combined with 
lactic acid according to the following formula. Formalin, 7 per 



3/4 DISEASES OF THE NOSE AND THROAT. 

cent. ; lactic acid, 50 per cent. ; glycerine, 20 per cent. ; and water to 
100 per cent. It is important to use a fresh preparation as the solu- 
tion loses its strength in a week or two. Formalin may also be used 
in powder as presented under the name para form. In efficient 
strength the applications are quite painful although the pain is not 
very lasting. Decidedly better results, as regards relief from pain 
and coughing, follow the use of orthoform or anesthesin. It may be 
mixed with an equal quantity of powdered gum acacia or subnitrate 
of bismuth and is free from objection on any ground. It acts best 
on an ulcerated or abraded surface. The parts having been gently 
cleansed with a detergent are sprayed with a two per cent, solution of 
cocaine, eucaine, or nirvanin. Thus the surfaces are benumbed and 
the powder, which should be applied liberally, is not rejected by the 
act of coughing. In this way a respite of several hours or more may 
be given. The remarkable effects of insufflations of resorcin in pro- 
moting the repair of ulceration have been affirmed by McCall and 
others. It is best applied every other day mixed with orthoform in 
the proportion of one or two parts in three. These measures are 
almost certain to allay pain, and if resorted to shortly before food is 
to be given the nutrition of the patient may be sustained much more 
effectively than would otherwise be practicable. If they fail to arrest 
the cough we shall be compelled to have recourse to opium or one of 
its alkaloids, heroin, codein, or morphine. The first mentioned is 
perhaps the best as regards certainty of action and freedom from 
unpleasant after-effects, although its precise status in therapeutics is 
not yet fully established, several cases in which rather alarming symp- 
toms followed its administration having been reported. In irritable 
pharynges and especially in the hyperemic form of tuberculosis ex- 
cellent results have been observed from spraying the larynx with a 
suprarenal extract solution containing one grain of phenic acid to 
each drachm. In these cases it is important to use only a straight 
spray, the patient being taught to inhale at the moment. With a 
down spray there is danger of provoking spasm of the larynx and a 
violent paroxysm of coughing. Long curved tubes intended for in- 
sertion into the cavity of the larynx itself are quite unnecessary. 

The modern method of treating tubercular laryngitis, by no means 
universally accepted, is based upon surgical principles as applied to 






TUBERCULOSIS OF THE LARYNX. 375 

tubercular deposits in other regions. An attempt is made to remove 
the diseased tissues by curetting, or excision, and to convert the tuber- 
cular lesion into a healthy granulating ulcer by destruction of the 
morbid structures with a corrosive acid, preferably lactic acid. Many 
years ago the practice of puncturing the edematous and infiltrated 
tissues was proposed by Marcet. The painful tension often present 
in these tumefactions is thus relieved. According to Moritz Schmidt 
the swelling subsides and in addition beginning ulcerations heal. The 
fear once entertained of infection and ulceration of the wounds thus 
made is not supported by clinical experience. On the contrary 
repair takes place and relief of odynphagia may be quite complete. 
In this connection it should be noticed that spontaneous repair of 
tubercular ulcers in the larynx has several times been observed. 
Tubercular subjects moreover, almost invariably improve temporarily 
under any new system of treatment and it is difficult at first to deter- 
mine how much potency should be ascribed to a new drug or appli- 
cation. Much -vaunted specifics prove after extended trial to be in- 
ert. One after another they have to be abandoned and the search 
for an antidote must be renewed. Hence one turns with hope to 
surgery, believing that although the disease itself may not be cured, 
prolonged suffering and a distressing death from an ulcerative tuber- 
cular laryngitis may be thereby averted. 

The details of treatment of a tubercular larynx by curetting are 
described as follows. In the first place the patient may have to be 
put through a course of training in order to overcome the intolerance 
of the passages. It is impossible to perform any manipulations in 
the larynx satisfactorily unless the parts are under control. Usually, 
even if they are very irritable, sufficient tolerance may be established 
by a preliminary spraying of the larynx and fauces with a ten per 
cent, solution of cocaine. In curetting the larynx the field of opera- 
tion is often embarrassingly obscured by the effusion of blood. This 
source of difficulty may be in a measure obviated by the use of a 
solution of suprarenal extract in alternation with cocaine. The ideal 
case for surgical treatment is one in which the tubercular infill ration 
is situated at the posterior wall of the larynx, either in the region of 
the arytenoids or at the posterior commissure. Tubercular deposits 
in other situations are less accessible but still if nol too extensive they 



376 



DISEASES OF TIIK NOSE AND THROAT. 



may be amenable to this mode of treatment. The parts having been 
prepared a laryngeal curette, of the model of Krause or Heryng (Fig. 
130), is passed into the larynx under the guidance of the mirror and 
the affected surfaces are thoroughly and boldly scraped until we are 
reasonably sure that the tubercular deposit has been completely re- 
moved, or has been sufficiently exposed. And here is the main diffi- 
culty. It is impossible to tell positively when the limits of the dis- 
ease have been reached. We are compelled to rely upon a judgment 
authorized by careful study of the parts beforehand. 

After the bleeding that has been excited has subsided we are ready 
for the application of the acid. The laryngeal applicator, wound 




I J K 

and Scarifiers. 

at the end firmly with a small pledget of cotton, is dipped into the 
solution of the acid, and passed into the larynx, the mirror showing 
the way as with the curette. It is not enough simply to touch the 
abraded surface ; the acid must be thoroughly rubbed in. The help 
of the patient is needed, and he should be taught to hold the tongue 
firmly between the folds of a napkin with the thumb and forefinger of 
the right hand. Lactic acid is said to have an affinity for morbid tis- 
sue and does not act upon healthy mucous membrane. While this 
statement may be true we should never begin treatment with the full 
strength of the acid, and care should be taken to avoid using an 
excessive quantity. It is best at first to use not stronger than a 
twenty per cent, solution, until we know what degree of reaction may 
be excited and how well the pain of the application may be endured, 
gradually increasing to full strength, if the patient is courageous and 
the parts not too sensitive. 



TUBERCULOSIS OF THE LARYXX. 377 

When the effect of the cocaine has worn off there is always more or 
less discomfort, and usually actual pain, which may last several hours. 
After the lapse of a week the process of rubbing in the acid may be 
repeated with increased strength. The number of applications will 
depend upon the situation and extent of the lesion and upon the effects. 
Usually we see, after the second or third application, an effort at 
repair of the ulcerated surface. It is well to suspend interference 
for a week or two, or until signs of arrest of the reparative process, 
or of the development of new tubercular foci are evident. Cicatriza- 
tion goes on with more or less rapidity until, in the course of two 
or three months, complete repair may be attained. It is unfortunate, 
however, that the cicatrices show a tendency to break down, either 
because of the failure of complete extirpation of the disease, or of 
inherent weakness in the tissues. 

The use of lactic acid following curettage has many opponents, both 
because of the excessive pain often incident to the treatment and for 
the more important reason that results are far from satisfactory. Bet- 
ter results with practically no discomfort to the patient are claimed 
by Freudenthal for an elaboration of the menthol treatment proposed 
years ago by Rosenberg. The details of this treatment are as fol- 
lows. The larynx is first thoroughly cleansed with some detergent 
solution, after which the parts are insufflated with three to six grains 
of powdered saccharated suprarenal gland. Cocaine has been dis- 
carded because of the paresthesia it causes in many patients, for the 
reason that it often affects the heart unfavorably, and finally on ac- 
count of the fact that its solution is prone to decompose. These 
objections do not apply to powdered adrenal. After a few minutes 
an emulsion of menthol-orthoform made by the following formula 
is slowly instilled with a laryngeal syringe: 

R. 

Menthol 1-15 

01. amygdal. dulc 3° 

Vitelli ovorum 25 

Orthoformi 1 -o 

Aquas destell. q. s. ad 100 

Ft. emulsio. 

The relief from pain lasts several hours or even days, so that a 
patient is able to take nourishment with ease. Under this method 



378 DISEASES OF THE NOSE AND THROAT. 

it is claimed that infiltrations disappear and ulcerations heal, and it 
apparently has no objectionable features. 

In the absence of ulceration excision of tubercular masses may be 
effected with a double curette or punch forceps. Applications or 
injections or cocaine, or nirvanin, permit this to be done without 
extreme pain. It is only suited to cases of very circumscribed dis- 
ease. Indeed radical interference of any kind should be reserved for 
limited ulcerations and infiltrations within easy reach, for primary 
laryngeal disease and for cases in which pulmonary disease is circum- 
scribed, incipient, and quiescent. It may be justifiable for the relief 
of excessive pain, or dysphagia, which yields to no milder measures. 
When the epiglottis alone is involved removal of this appendage 
through the mouth is feasible and seems to entail no special incon- 
venience. Such cases have been reported by Solis-Cohen and Hajek. 
and R. Lake mentions having three times removed the larger part 
of the epiglottis with the galvanocautery snare without pain and with 
good effect. Ulceration in this situation is often very distressing, 
yet a patient under my observation at the present time has lost nearly 
one third of his epiglottis and has never had a particle of pain. In 
laryngeal operations of this kind it is absolutely necessary that we 
should have the full consent and cooperation of our patient, not to 
mention the need of more than average dexterity on the part of the 
operator. Attention has been called by Lake to the occurrence of 
postoperative pyrexia as a positive indication for discontinuing opera- 
tive interference. 

In line with this mode of attacking tuberculosis of the larynx it 
may be mentioned that thyrotomy has several times been resorted to 
and that laryngectomy has been done fifteen times for actual or sup- 
posed tuberculosis, eight total and seven partial operations (Gleits- 
mann). It is hard to conceive that any circumstances would justify 
these procedures. On the theory that rest of the larynx is essential 
to secure repair of laryngeal ulcerations tracheotomy was practiced 
for several years. My experience with it leads me to believe that it 
merely adds one more source of discomfort without commensurate 
advantage. When the condition has become so serious that feeding 
by enemata or with an esophageal tube must be considered the time 
for active treatment of any kind is past and palliation is our last 
resource. 



TUBERCULOSIS OF THE LARYNX. 379 

The influence of the chemical rays of light upon morbid processes 
has long been appreciated, and the subject has been recently taken up 
with renewed interest. In ancient times sun and air were considered 
essentials to health and life, and all the customs of the people were 
based on this idea. Electric light produces effects upon the system 
similar to those of sunlight, and modern phototherapy is the direct 
outcome of the old theory of light as a therapeutic agent. The power 
of sunlight at least to retard the growth of tubercle bacilli in culture 
tubes seems to have been demonstrated. The stimulus of light to 
the function of ciliated epithelium expedites chemical changes, or in 
other words oxidation, which result in activity. Thus the rays of 
light do double duty in destroying germs and in exciting movements 
of cilia which serve to clear out secretions and irritating particles 
from the upper air-track. Especial attention has been given to this 
matter by Freudenthal, who has experimented with the arc light and 
the incandescent light in tuberculosis of the lungs as well as of the 
larynx. A special lamp not yet perfected is designed to be placed 
over the thyroid and held in position for from thirty to sixty min- 
utes. In cases of tubercular ulceration and infiltration of the larynx 
the subjective symptoms were relieved and a definite cure of the 
laryngeal lesion was observed. This method, which is certainly free 
from disagreeable features, is deserving of further trial. In this 
connection the observations of Wolfenden and Ross as to the thera- 
peutic effect of the X-rays are of interest, their conclusion being that 
the rays stimulate rather than check the growth of bacilli. 

Submucous and intratracheal injections of various substances, as 
advocated by Watson Williams, Chappell, Donellan and others, espe- 
cially creosote, guaiacol, 20 per cent., lactic acid, and biniodide of 
mercury, 1 to 1,000, have not been widely adopted, but they seem to 
be efficacious in some cases. The galvanocautery is used by a lim- 
ited number, but is generally regarded as more or less dangerous. 
Williams in particular advises the galvanocautery point in the sub- 
glottic region for flat diffuse infiltrations which cannot be easily 
reached with forceps. In the experience of some it has never caused 
an acute edema of the glottis or violent reaction of any kind, and it 
is especially recommended by Gouguenheim and Tissier for fungous 
vegetations, or " pseudo-polypoid " formations. 



380 DISEASES OF THE NOSE AND THROAT. 

Electric cataphoresis, whereby the tissues are saturated with a 
medicament antagonistic to the morbific germ and stimulant to 
healthy repair, deserves more attention than it appears to have re- 
ceived. Guaiacol and oxychloride of copper have given the most 
satisfaction. Spherical electrodes of pure copper are preferred to 
needles for use in the larynx, since the former make no lesion of the 
mucous membrane. A weak galvanic current with the positive pole 
connected with the laryngeal electrode and the negative applied to 
the nape of the neck, may be used every other day, the interval and 
the duration of the sittings being regulated by the strength of the 
patient and the results. Some throats are so irritable that this method 
is not feasible even with cocaine anesthesia. The following advan- 
tages are claimed for cupric electrolysis (Scheppegrell). (1) There 
is no destruction of tissue, or lesion of the surface through which 
pathogenic germs may reinfect the system. (2) There is no reac- 
tion nor hemorrhage. (3) It requires no extraordinary skill, and 
is especially easy when direct laryngoscopy (Kirstein) can be used. 
(4) It is applicable to all cases of laryngeal tuberculosis. 

Percutaneous galvanism and faradization have been used in tuber- 
culosis of the larynx to a limited extent with apparently definite and 
favorable results, but no final conclusion regarding them has been 
reached. 

It is somewhat the custom to pronounce the doom of an individual 
discovered to have tuberculosis and to content ourselves with efforts 
to ease his steps to the grave. Experience teaches that this desperate 
view should not be entertained. A few cases get well, some are 
cured, many have their lives prolonged, a large proportion are inevita- 
bly fatal. Yet we should not sit inactive and permit the ravages of 
the disease to go on unresisted. It is rather our duty, without relax- 
ing the search for a remedial agent, to teach that hygienic living, pure 
air, and good food furnish the most effective weapons against the 
approach of the subtle enemy. As indispensable adjuvants we should 
insist upon voice rest, the avoidance of local irritants of every kind, 
the adoption of a diverting occupation, and abstention from over- 
exertion and physical fatigue. All of these conditions, which render 
home treatment possible and most desirable, are at the command of 
only the well-to-do. Segregation of those less fortunate in hospitals 



TUBERCULOSIS OF THE LARYNX. 38 I 

and sanatoria should be under the strictest surveillance. Although 
tubercular subjects are as a rule sanguine and cheerful, yet upon 
certain temperaments the depressing effect of intimate association 
with other invalids is quite detrimental. 

The principles governing the question of radical interference as 
laid down by Heryng are believed to be logical. In brief he regards 
cases of advanced pulmonary disease attended by hectic and emacia- 
tion, diffuse miliary tuberculosis and extreme inflammatory stenosis 
of the larynx as decidedly inappropriate for operation. In addition 
it is contraindicated in neurotic and timorous patients in bad general 
condition. Suitable cases for such treatment are few ; cures in the 
proper sense of the word are fewer still ; but even from the most con- 
servative standpoint, except in extreme cases, we have within reach 
the means which enable us to assure amelioration of symptoms and 
prolongation of life. Obviously when called upon to treat a case of 
laryngeal tuberculosis we are brought face to face with a complex 
problem to be viewed from many sides. We may at least refrain 
from inflicting additional torture upon the sufferer by useless and 
possibly harmful local meddling. 



CHAPTER XXII. 

S\ I'llILIS OF THE LARYNX. 

The lesions of hereditary syphilis in the larynx are somewhat rare. 
It may be admitted that a syphilitic dyscrasia is responsible for many 
derangements of the air-track in the new-born, but that pathological 
phenomena characteristic of syphilis are as frequent in hereditary as 
in the acquired disease is by no means established. On the other 
hand J. N. Mackenzie believes that laryngeal lesions in congenital 
syphilis are not infrequent, and are simply not found because not 
sought. Two cases have been reported by Monti of syphilitic devel- 
opment in the larynx in intra-uterine life. A division into secondary 
and tertiary is not found to Ik- practicable, the first manifestations of 
hereditary syphilis often being deep destructive ulcerations. Usu- 
ally the laryngeal lesions are associated with or follow characteristic 
affections of the eye, malformations of the teeth, or other phenomena 
distinctive of syphilis. Two thirds of the cases occur in the first year 
of life. Alteration of the voice and of the cry of the child, the occur- 
rence of cough, dyspnea and attacks of laryngismus are commonly 
observed. Laryngoscopy is difficult but by no means impossible in 
the early years of life. Kirstein's mode of examining the larynx 
may be found feasible when the ordinary methods fail. 

The best treatment of hereditary syphilis of the larynx consists of 
inunctions with mercurial ointment or the internal administration of 
gray powder. Some cases do better when mercury is combined with 
the iodides or hydriodic acid, or with general tonics. 

Locally, mentholized or borated albolene in vapor or spray has a 
beneficial effect. The question often arises whether in the existence 
of evidences of active hereditary disease, enlarged tonsils and aden- 
oid^ should be removed. The coexistence of a syphilitic taint should 
certainly not be regarded as a contraindication, if it is evident that 
these hypertrophies are making an impression upon the general 
health. Intralaryngeal infiltration <>r distortion from cicatricial con- 

382 



SYPHILIS OF THE LARYNX. 383 

traction may so impair the lumen of the child's larynx as to suggest 
the necessity of tracheotomy or intubation. The latter mode of re- 
lieving the stenosis is preferable unless an excessive amount of 
cicatricial tissue be present. If the obstruction of the larynx 
has come on rather gradually it is probably due to cicatrices and, 
whether in children or adults, we are confronted by a most serious 
complication which is capable of relief only after a very tedious and 
rather unsatisfactory course of treatment. Internal medication can- 
not be expected to make any impression on adventitious bands of scar 
tissue, and we are forced to choose between the introduction of a 
trachea tube, an intubation, and division with dilatation of the stric- 
ture. A tracheotomy may be required as a preliminary to attempts 
to overcome the stenosis by the use of bougies. Months and even 
years may be spent in the process of stretching a syphilitic stricture 
of the larynx and after all the result may not be permanent. In any 
case the phonatory function of the larynx will have been impaired or 
lost. Experience with the O'Dwyer tube of vulcanite or metal is 
quite encouraging. The metal tube has a proportionately larger 
lumen and its weight tends to keep it in place. In one of O'Dwyer's 
cases the tube was worn upwards of a year. In the exhaustive re- 
ports on this subject by Lefferts and by W. K. Simpson abundant 
evidence appears of the value of intubation in these cases and of the 
ease with which the tube is tolerated for a very long period. In 
view of the tardy and often disappointing results from this method 
partial resection of the larynx has been advocated by certain authori- 
ties. Schroetter, a most enthusiastic partisan of systematic dilatation 
after tracheotomy, has had several successful cases with the use of 
tubes of gradually increasing diameter, and similar success has been 
achieved by others (Fig. 131). Dilatation from below through a 
trachea tube has been recommended by Stoerk and may be prefer- 
able in some cases. Rapid stretching of a syphilitic stricture is almost 
invariably followed by excessive inflammatory reaction and should 
never be employed. The " dilating laryngotome " of Whistler, an 
almond-shaped dilator in which is concealed a knife blade to be pro- 
truded by a lever in the handle of the instrument, seems to have given 
excellent satisfaction in many cases. It has been modified by 
Lennox Browne by making the shaft of the instrument hollow and 



3«4 



DISEASES OF THE NOSE AND THROAT. 



thus the operator is enabled to make the incisions with more delibera- 
tion and certainty without fear of completely obstructing the air- 
track. The results of treatment are much more gratifying and per- 
manent in the larynx, as elsewhere, provided the bands of scar tissue 
are thin and not very numerous. In many cases, especially if the 
stenosis involves the trachea as well as the larynx, the only resource 
is a trachea tube to be inserted as low as possible and permanently 
retained. Stenosis of the larynx developing somewhat rapidly is 
generally caused by edema or by gummatous infiltration. The mar- 
vellous and prompt relief given in these cases by internal medication, 
even when a tracheotomy seems unavoidable, has been insisted upon 




Fig. 131. Schroetter's Laryngeal Dilator. 
The metal plug is attached to the introducer by a twine which is drawn through 
the hollow handle by means of the slender flexible hook. The plug fits into the 
fenestra of the trachea tube and is held in place by the inner tube the upper part 
of which is prolonged as a solid rod. 

by Krishaber and others. A boy, ten years of age, was once brought 
into my clinic cyanotic and gasping for breath. There seemed to be 
no time to ask questions, so I at once opened the trachea. The his- 
tory of the case afterwards obtained proved clearly that the boy was 
a victim of hereditary syphilis. The usual treatment was followed 
in a few days by subsidence of the laryngeal stenosis so that it was 
possible to remove the trachea tube. The laryngoscope showed ex- 
treme deformity of the larynx from old ulceration and cicatricial 
bands, but the breathing space was ample and very likely might have 



SYPHILIS OF THE LARYNX. 385 

been rendered so by internal medication alone without the aid of a 
tracheotomy. 

The lesions of acquired syphilis of the larynx are limited to those 
of the so-called secondary and tertiary periods. Wide discrepancies 
exist among - authorities as to the frequency of its occurrence, one 
observer having met with it in only 2.9 per cent. (Lewin) of all 
laryngeal cases observed; another found it in 34 per cent. (Som- 
merbrodt). 

Predisposing causes of syphilis of the larynx in the acquired dis- 
ease are preexisting catarrhal conditions, neglect of treatment in the 
early stages, and bad hygiene such as often prevails among the poorer 
classes. Primary syphilis has not been met with in the laryngeal 
cavity. A case of chancre of the epiglottis reported by Moure is 
unique. 

Secondary lesions generally coexist with a cutaneous eruption, or 
closely follow it. An erythema of the larynx is very apt to accom- 




Fig. 132. Early Secondary Lesions of Vocal Bands. (Schnitzler.) 

pany a similar condition in the fauces, and differs but little from a 
simple erythema except that the redness of the former is less intense 
and less diffuse, the membrane having a mottled appearance. It 
causes no symptoms of importance except more or less hoarseness, 
and requires no very energetic local treatment (Fig. 132). 

The possibility of the occurrence of mucous patches in the larynx 
has been denied by many excellent observers, hut numerous authentic 

25 



386 DISEASES OF THE NOSE AND THROAT. 

cases are now on record. When presenl on the epiglottis they often 
appear as condylomata or warty excrescences. These lesions are sel- 
dom symmetrical. They disappear under treatment or spontaneously 
but are prone to recur. They are often found associated with gen- 
eral erythema which involves the pharynx as well. They may be 
single or multiple and in the mirror present the appearances charac- 
teristic of mucous patches in other regions, namely, elevated erosions 
with a surface of a peculiar grayish hue and surrounded by a more 
or less pronounced areola of redness. It is quite probable that the 
existence of mucous patches in the larynx often fails to attract atten- 
tion on account of the slight functional disturbance they excite, and 
of the greater importance of coincident symptoms. 

The form of superficial ulceration named by Whistler " relapsing 
ulcerative laryngitis " possibly begins as a mucous patch. The voice 
is generally husky and raucous. The singing voice is likely to be 
absolutely abolished and the probability of its recovery is very doubt- 
ful. Respiration may be wheezy. There is more or less irritating 
cough without an excessive amount of expectoration. There is sel- 
dom any pain. In examining the larynx with a mirror we find in- 
stead of a uniform redness of the mucosa a mottled hyperemia, and 
erosive patches may be seen on the ventricular bands, upon the free 
edge of the epiglottis, on the arytenoids, or at the posterior commis- 
sure. Gottstein describes them as " round or elongated grayish- 
white spots of thickened epithelium, slightly raised above the con- 
gested tissue which surrounds them, and either sharply circumscribed 
or shading off into the congested mucous membrane." Ordinarily, 
there is no very obvious change in the texture and conformation of 
the mucous lining of the larynx except in the existence of diffuse 
condylomata. Occasionally the edges of the vocal bands may be 
eroded or notched and adhering to them may be seen masses of viscid 
secretion. Usually confirmatory symptoms elsewhere in the body are 
present. A cutaneous eruption, posterior cervical or epitrochlear 
lymphadenitis, or some of the other well-known symptoms of sec- 
ondarv syphilis, may establish the diagnosis. The impairment of 
general health may be no more than might be reasonably expected 
from the systemic disturbance unless the laryngeal lesions are so 
aggravated as to interfere with rest at night, or with comfort by 
day (Fig. 133). 



SYPHILIS OF THE LARYNX. 387 

The so-called tertiary lesions of acquired syphilis are of much more 
serious importance. They may begin in the deeper tissues or may 
reach them by extension from the surface of the mucous membrane. 
They occur as gummatous tumors or infiltration and as ulcerations 
superficial or deep, resulting from disintegration of gummatous infil- 
tration. The latter present the form of circular or crescentic ulcers, 
with sharp elevated edges, sometimes undermined, surrounded by an 
inflamed areola. The color of the mucous membrane is somewhat 




Fig. 133. Superficial Lesions of Vocal Bands in Early Syphilis. 
(Schnitzler.) 

less red than in simple inflammations. The resultant deformity 
varies with the degree of infiltration, the loss of tissue, or the disposi- 
tion and extent of cicatricial formations. The effect upon the voice 
depends entirely upon the site of the lesion, whether upon the vocal 
bands themselves or at some point where the action of the intrinsic 
muscles of the larynx is only slightly interfered with. Dypsnea may 
be due to infiltration, cicatricial contraction, edema, or anchylosis of 
the cricoarytenoid joint. More or less cough is usually present, and 
the expectoration is sometimes streaked with blood when an active 
ulcerative process is present. Deglutition may be impaired and pain- 
ful if an ulcer involves the margin of the glottis. There may be no 
cachexia or impression upon the general health unless swallowing is 
interfered with (Fig. 134). 

In all therapeutics there is no more satisfactory and definite result 
of treatment than in the disappearance of a gummy tumor under the 



388 DISEASES OF THE NOSE AND THROAT. 

influence of iodide of potash, provided the stage of softening has not 
been reached. It is a remarkable fact that one of these tumors may 
remain quiescent for months or even wars and then from some inex- 
plicable cause begin to break down and ulcerate. A gummatous in- 
filtration may be diffuse or in the form of circumscribed tumors, 
single or multiple. Dyspnea is proportionate to the degree of en- 
croachment on the respiratory track and interference with phonation 
varies with the relation of the lesion to the vocal bands. There is 
always danger of an access of inflammation or edema which may 
cause a dangerous stenosis. There is seldom much pain unless the 
rim of the glottis is involved in ulceration, or the perichondrium and 
the cartilages become affected. Necrosis or caries of the cartilage 
may take place. A fragment of dead cartilage may be extruded in 
the act of coughing, or may become embedded in a dense mass of 





Fig. [34. Destruction of Vocal Hands by Late Syphilitic Ulceration". 
(Schnitzler. 1 

cicatricial tissue. Usually a gummy tumor develops rather rapidly 
and presents as a symmetrical painless tumefaction covered by nor- 
mal mucous membrane. It may be impossible, especially in the 
absence of a positive specific history, to differentiate the condition 
from a malignant neoplasm without resort to a test with antisyphilitic 
treatment. The importance of recognizing a gummy tumor before 
the process of disintegration has begun must be obvious. When 
ulceration is established we have to look forward to the deformity 
from distorting scars which always follows repair of a syphilitic ulcer. 
The prognosis in tertiary syphilis should be guarded. The patient 
may be in danger from edema implanted upon a more or less exten- 
sive infiltration, or from hemorrhage due to invasion of a blood- 
vessel by an ulcerative process. 



SYPHILIS OF THE LARYNX. 



389 



The treatment should be active and in accordance with the method 
of treating syphilis in general. In secondary laryngeal lesions mer- 
curials are indicated and, locally, the condition should be handled by 
soothing or stimulating inhalations as in simple chronic laryngitis. 
Nitrate of silver, unless ulcerations are present, is best avoided from 
its tendency to promote hyperplasia. In the deeper tertiary lesions 
the iodides in rapidly increasing doses, combined with cod-liver oil 
and general tonics, and alternating with mercurial inunctions, or used 
together with them, will give the best results. In the tertiary ulcers, 
nitrate of silver in strong solutions, or fused on a probe, and even 
the galvanocautery, may be required to stimulate healthy reparative 
action. Stenosis due to infiltration will usually yield to saturation 
of the system with the iodides. The management of that resulting 
from cicatricial contraction has been described. 



CHAPTER XXIII. 

NEUROSES OF THE LARYXX. HYPERESTHESIA. ANESTHESIA. PARES- 
THESIA. NEURALGIA. HYSTERICAL APHONIA. LARYNGEAL 
VERTIGO. CHOREA. SPASM OF THE LARYXX. LARYN- 
GEAL STRIDOR AND WHISTLING. PARALYSIS OF 
THE LARYXX. 

SENSORY NEUROSES. HYPERESTHESIA OF THE 
LARYXX. 

Hyperesthesia, or excessive sensitiveness of the larynx, is usually 
symptomatic of some inflammatory condition, and is especially noted 
in phthisis and in carcinoma. The degree of normal sensitiveness 
differs greatly in different individuals and is apt to be more marked 
in those of nervous temperament. It is exaggerated in alcoholics, 
while, in syphilis, it is usually diminished. In conjunction with 
abnormal pallor of the mucous membrane it must be regarded as of 
rather serious import in relation to the probable development of tuber- 
culosis. 

ANESTHESIA OF THE LARYNX. 

Anesthesia of the larynx may result from some lesion involving the 
trunk of the superior laryngeal nerve. It is frequently marked in 
central nervous troubles, in hysteria, and as a sequel of diphtheria. 
In some cases of chronic laryngitis there is diminution in the sensi- 
tiveness of the laryngeal mucosa. In anesthesia of central or bulbar 
origin nothing can be effected by treatment. In other cases the use 
of nerve tonics is indicated, and faradism is of service, the internal 
electrode being placed in the sinus pyriformis in order to bring it as 
near as possible to the superior laryngeal nerve (Ziemssen). If the 
lesion is bilateral there is danger from the entrance of food or foreign 
bodies into the air passages. 

39° 



NEURALGIA OF THE LARYNX. 391 

PARESTHESIA OF THE LARYNX. 

Paresthesia, or perverted sensation, of the larynx, includes burn- 
ing, tickling, a sensation of a foreign body, a constant desire to swal- 
low, and a simple feeling of irritation. It may be associated with 
some organic structural lesion, or the consequence of lymphoid hyper- 
trophy at the base of the tongue. It may occur as a reflex phenom- 
enon from disease in some remote region, or it may be merely a 
symptom of neurasthenia or hysteria. The tickling sensation is very 
annoying, and occurring in the course of certain tubercular lesions 
of the larynx or in the pretubercular stage, is provocative of distress- 
ing cough. 

NEURALGIA OF THE LARYNX. 

Neuralgia of the larynx is said to occur in the course of rheuma- 
tism and gout and in malaria. Pain is a prominent symptom in can- 
cer and phthisis and in connection with some acute inflammatory 
troubles, but genuine functional neuralgia of the larynx is believed 
to be a rare occurrence. Associated with spontaneous pain there may 
be tenderness on pressure over the larynx externally, especially in the 
vicinity of the greater cornu of the hyoid. There is no abnormal 
appearance to be seen in the laryngeal mirror. Reported cases, like 
that of Schnitzler, in which the pain was so intense that the patient 
was on the verge of suicide, and which was cured by brushing the 
larynx with a solution of chloroform and morphine, and like that of 
Bosworth, in which tracheotomy was contemplated for the relief of 
a sense of suffocation and in which a cure was effected by aconitia 
pushed to its physiological effect, would suggest that the condition 
must be regarded as, in large part, hysterical. In all probability, any 
pronounced impression would have induced a cure. Such cases are 
amenable to hypnotic suggestion. Most of these sensory neuroses 
occur in neurotic subjects and in those in impaired general health. 
The indications then are clearly for the use of general tonics and good 
hygiene, combined with mental diversion. The galvanic current, the 
positive pole in the larynx, has been found beneficial. 



39- DISEASES OF THE NOSE AND THROAT. 

MOTOR NEUROSES. HYSTERICAL APHONIA. 
An interesting functional neurosis not infrequently met with in 

females, hysterical aphonia, is characterized by complete loss of voice 
without any gross lesion of the larynx. Phonatory movements of the 
larynx are symmetrical but incomplete; the cords fail to approximate 
in attempts at phonation, or at once retreat after momentary adduc- 
tion, and the patient merely succeeds in producing a whisper. The 
loss of voice may be as complete as in inflammatory conditions, but 
while the laryngeal picture in the latter is abnormal, in hysterical 
aphonia there is no deviation from health. The ability to cough is 
retained, this condition thus differing from a genuine paralysis, and 
under general anesthesia phonatory power is usually restored. There 
is rarely any interference with breathing, a single case having been 




Fig. 135. Hysterical Paralysis of Adductors. {Schnitzler.) 

reported by Meschede in which the affection simulated bilateral abduc- 
tor paralysis, and the necessity of opening the trachea was being 
considered, wdien the voice was suddenly recovered and the dyspnea 
ceased. The loss of voice and its recovery are generally equally 
abrupt. The occurrence of sudden shock or extreme excitement will 
act as a stimulant to phonation or, if any doubt remains as to the 
character of the trouble, the administration of an anesthetic will clear 
it up. Not infrequently hysterical aphonia is of reflex character 
dependent upon uterine disease, or upon some lesion in the nasal 
chambers or the naso-pharynx (Fig. 135). 

LARYNGEAL VERTIG< ). 

Laryngeal vertigo, also called laryngeal apoplexy, laryngeal syn- 
cope and complete glottic spasm, is a rare condition usually preceded 



NEUROSES OF THE LARYNX. 393 

by a sensation of tickling or discomfort in the larynx and paroxysmal 
cough. The patient grows dizzy, generally falls, becomes momenta- 
rily unconscious, and presently recovers without any subsequent ill 
effects. There are sometimes some congestion of the face and slight 
convulsive movements which are not to be confounded with those 
of true epilepsy. The condition resembles somewhat the epileptiform 
seizures which occur in tabes. There is no laryngeal lesion dis- 
coverable. Charcot likens it to Meniere's disease and believes it is 
reflex in character, resembling the vertigo occurring in aural and 
gastric disturbances. Nearly all the cases observed occurred in males 
past middle life. The attacks may vary from a single one to as many 
as fifteen a day as reported by Charcot. McBride believes the at- 
tacks are due to forced expiratory efforts against a partially closed 
glottis which causes congestion as in prolonged paroxysmal cough 
and whooping-cough. F. I. Knight, who has made a careful study 
of this subject, corroborates the views of McBride in large part, but 
notes the fact that the presence of spasm of the glottis in most cases 
has not been proved, and he surmises that even in its absence the 
head symptoms and loss of consciousness occurring in these cases 
may be readily explained by the disturbance of the cerebral circula- 
tion consequent upon rapid respiration. 

The prognosis is good. There is seldom any serious complication 
and the correction of any local disease or general disturbance should 
be followed by a disappearance of the laryngeal symptoms. In all 
cases careful examination should be made of the pharynx, base of 
the tongue and upper air-track ; not infrequently hyperemia or varix 
at the base of the tongue will be discovered which may be relieved 
by the use of the galvanocautery. Astringent applications to the 
pharynx and counter-irritation over the larynx have been recom- 
mended. 

In some cases the bromides or other nerve sedatives, iron, ergot 
and salines will be found beneficial and careful attention should be 
paid to the diet and the condition of the digestive track. Stimulants 
should be avoided. 



394 DISEASES OF THE NOSE AND THROAT. 



CHOREA OF THE LARYNX. 

Chorea of the larynx usually occurs in connection with some other 
neurotic symptom or with general chorea. Almost invariably a local 
lesion like an elongated uvula, hypertrophy of the glands at the base 
of the tongue, or enlarged tonsils will be found to coexist as an excit- 
ing cause. The most conspicuous symptom is a dry explosive cough 
at short intervals through the day only. The voice is not affected, 
although phonation may be somewhat jerky. It is usually met with 
in girls approaching maturity, although one case has been observed 
at the age of forty-two (F. I. Knight). Gottstein believes that 
many of these cases are examples of so-called " nervous cough " 
rather than a genuine chorea, but so many cases have been reported 
by such careful observers as Lefferts. Roe and others that there can 
be no doubt as to the occasional occurrence of true choreic spasm 
of the glottis. The best results in treatment have followed the adop- 
tion of good hygiene, the use of electricity, bromide of potassium 
internally, or Fowler's solution in physiological doses. In all cases 
nasal stenosis should be corrected, and the abnormalities above re- 
ferred to must be removed. 



SPASTIC APHONIA. 

Spastic aphonia, or dysphonia, is the name given to a condition of 
violent adductor spasm occurring only on attempts at phonation and 
ceasing when the effort to speak is discontinued. It has been ob- 
served only in adults and generally in females. It is apt to follow 
■ iveruse of the voice and has been compared by Schnitzler to " writer's 
cramp." In some cases the cartilaginous portion of the glottis re- 
mains open, in others the adduction is so forcible that the vocal bands 
actually overlap and stenosis is complete. In some the spasmodic 
movements are irregular, or clonic, producing what has been called 
by Janus " stammering of the vocal cords." In some cases the 
attacks increase in frequency and severity and are finally excited 
by other causes than the attempt to speak. Distinct pain or a feel- 
ing of cramp in the region of the larynx is sometimes present. 



SPASM OF THE LARYNX. 



395 



SPASM OF THE LARYNX IN CHILDREN. LARYNGIS- 
MUS STRIDULUS. 

Spasm of the larynx, or paroxysmal closure of the glottis, may be 
caused by some irritation of the recurrent laryngeal nerve, or of the 
trunk of the vagus, or may be of purely reflex origin, as from aden- 
oids, difficult dentition or intestinal parasites. In children it is most 
common in the first two years of life and may be produced by very 
slight causes. It is more frequent in male children and in the winter 
months. Ill-nourished rachitic children are especially prone to laryn- 
gismus. In these cases also glandular enlargements, particularly 
affections of the bronchial glands, and diseases of the nervous sys- 
tem, notably hydrocephalus, are named as etiological factors. In 
children of highly nervous temperament a catarrhal inflammation of 
the larynx, or of the air-track generally, gastric or intestinal irrita- 
tion, or any profound emotion may induce an attack. Usually there 
are no premonitory symptoms. The child goes to sleep at night in 
usual health, is suddenly wakened and after giving two or more short 
crowing inspirations ceases to breathe. After a few seconds and sev- 
eral long noisy inspirations normal respiration is resumed. Such 
attacks may be repeated at short intervals and interfere but little with 
health or comfort except at the time. In more severe cases the mus- 
cles of the extremities may be involved and general tonic convulsions 
may occur, with momentary loss of consciousness and irregular heart 
action. Attacks of this type are very terrifying as well as dangerous. 
In the milder cases it is noticed that the paroxysms are more apt to 
come on at night and that the intervals between them are shorter. 

The prognosis is generally good, the liability disappearing with 
improvement in nutrition and decrease of nervous irritability. Death 
occasionally occurs in weak children from asphyxia or general con- 
vulsions. A fatal result may also follow sooner or later from pres- 
sure due to effusion in the ventricles of the brain. When the attacks 
are severe and frequent so that the general health begins to suffer the 
outlook is less favorable. 

In the treatment of this condition it is important that attention be 
directed to the creneral health with a view of warding: off the attacks. 



3<?6 DISEASES OF THE NOSE AND THROAT. 

At the same time the paroxysm itself must be relieved if possible, 
although it is clear that many of the measures resorted to under these 
circumstances arc utterly useless. Yet in the presence of relatives 
frantic with fear and of a child cyanotic and apparently dying from 
apnea we are obliged to do something. In severe cases swallowing 
is impossible and respiration is suspended so that we are debarred 
from the use of internal remedies and inhalations until the spasm 
subsides. Tight clothing should be loosened and a supply of fresh 
air furnished by opening the windows. Friction of the extremities 
and purgative enemata are indicated. Immersion in a hot bath with 
cold affusions to the head may be useful. When the spasm does not 
yield catheterization of the larynx, intubation, or tracheotomy may be 
called for. The first mentioned is recommended by Gottstein. As 
a rule the case terminates by relaxation of. the spasm or asphyxia 
before these resources can be made available. Artificial respiration 
and possibly stimulation of breathing by electricity may be of service. 
In the intervals the diet must be carefully regulated as regards both 
quantity and quality of food. Gastrointestinal derangements must 
be corrected and excessive nervous irritability must be controlled by 
sedatives, especially bromide of potash. Antipyrine has been used 
successfully, and various antispasmodics are now and then resorted 
to. Rickets, struma, lymphadenitis, anemia and other constitutional 
disorders require appropriate treatment. The use of morphine would 
probably be considered inadvisable by most practitioners, yet Bos- 
worth regards a sixteenth of a grain of morphine combined with one 
five-hundredth of atropine hypodermically as effective and quite safe 
in a child of eighteen months. Scarification of the gums should be 
done in impeded dentition, and feeding with a spoon instead of allow- 
ing the child to take the breast, when as occasionally happens the act 
of nursing seems to excite an attack, should be tried. In high-strung 
nervous children the avoidance of undue excitement is very impor- 
tant. 

SPASM OF THF LARYNX IN ADULTS. 

The occurrence of spasm of the larynx in adults is very rare. 
Among the most frequent causes may be mentioned hysteria and 
pressure upon the pneumogastrie or inferior laryngeal nerve by a 



NEUROSES OF THE LARYNX. 397 

new growth or an aneurismal tumor, the compression being suffi- 
cient merely to irritate the nerve trunk without completely impeding 
its function. In epilepsy, hydrophobia, tetanus, chorea and locomotor 
ataxia spasm of the glottis is not uncommon. It frequently follows 
a local application to the larynx, especially if much force be used or 
the character of the application be irritating. Foreign bodies are 
very apt to provoke a spasm ; neoplasms are less likely to do so 
because in their process of slow development the parts become accus- 
tomed to their presence. Bosworth refers to cases cured by correc- 
tion of a deviated septum, reduction of nasal hypertrophies and 
removal of nasal polypi, and mentions having seen " some very in- 
teresting cases of laryngeal spasm in the chronic pharyngitis of alco- 
holism." A unique and perhaps dubious case is that of Hack in 
which the spasm is supposed to have been induced by a hyperemic 
condition of the mucous membrane of the pyriform sinus in which 
situation the superior laryngeal nerve is quite superficial. Except 
when occurring as a phenomenon of locomotor ataxia the seizures are 
generally nocturnal. They are very transient and seldom involve 
any danger to life except in tabes, although Heryng reports several 
cases of reflex spasm from intranasal disease in which tracheotomy 
was required. The treatment of the case otherwise depends upon 
the cause. Local lesions of the upper air-track must be corrected and 
so-called nerve tonics and sedatives may be indicated. Nearly all 
patients of this class are below par in general health and in a state of 
nervous erethism which predisposes them to all sorts of functional 
disturbances. Any modification of regime or habits which may con- 
tribute to improvement in these particulars must be enforced. 



LARYNGEAL STRIDOR AND LARYNGEAL WHISTLING. 

Two curious conditions are met with in young patients which may 
be mistaken for more serious lesions. The first, laryngeal stridor, 
appears in infants at or soon after birth, and is sometimes accom- 
panied by a moderate amount of cyanosis and dyspnea. There is no 
aphonia. A difference of opinion exists as to its cause. It resem- 
bles ordinary laryngismus stridulus and has been considered by some 
a reflex spasm due to adenoids. Others believe that it is caused b) 



39§ DISEASES OF THE NOSE AND THROAT. 

a paralysis of the posterior crico-arytenoid muscle. It seems prob- 
able, however, that it is due simply to that flaccidity of the laryngeal 
structures which exists in early life (Sutherland and Lack). The 
epiglottis folds on itself and the resilient walls of the larynx tend to 
collapse, thus impeding respiration. The condition is rarely danger- 
ous and ordinarily requires no special treatment. Examination of 
the larynx is not easy and it might be difficult to differentiate this con- 
dition from that resulting from papillomatous growths or membran- 
ous obstruction. 

After a very thorough study of the subject, A. Logan Turner and 
John Thomson reach the following conclusions: that the stridor is 
due to disturbance of respiratory coordination probably resulting from 
faulty or retarded development of the cortical center; that the altered 
conformation of the larynx is not congenital but is merely an exag- 
geration of the infantile type resulting from the constant sucking in 
of the aperture of the soft larynx in the peculiar breathing ; that the 
sound is not pharyngeal nor tracheal, but is made in the larynx ; that 
this neurosis is not due to adenoids or other reflex irritation. They 
believe that enlargement of the thymus or lymphatic glands is not 
concerned, because these lesions were not found in several cases ex- 
amined post mortem, and because in two cases of pressure from en- 
larged glands the stridor was chiefly expiratory, the larynx did not 
move up and down in respiration, and respiratory distress was much 
more marked than it commonly is in cases of intralaryngeal obstruc- 
tion. It is supposed that the stridor in the class of cases under dis- 
cussion is produced partly in the larynx and partly by abnormal 
approximation of the aryepiglottic folds. 

A very rare and curious phenomenon has been described under the 
name of " laryngeal whistling." A recent case was that of a boy of 
thirteen who produced a strange shrill whistle with the mouth wide 
open. It was possible to examine the boy with a mirror, but it was 
found in the production of the sound that the epiglottis was forcibly 
drawn downwards so as to prevent a view of the interior of the 
larynx; hence, it was impossible to determine precisely the origin of 
the sound, whether produced in the chink formed by forcible retrac- 
tion of the epiglottis, or by the aryepiglottic folds, or by an extraor- 
dinary degree of tension of the cricothyroid muscles over which the 



PARALYSIS OF THE LARYNX. 



399 



patient might, perhaps, have an unusual amount of control. It has 
been suggested also that this lad might have caused the sound with 
a membranous formation similar to the syrinx of birds. In a similar 
case reported several years ago by John O. Roe it was possible to 
study the parts during production of the sound, the patient being an 
adult and very manageable. This observer concludes that the whistle 
was produced by vibration of the vocal bands only in their middle 
third, the limitation of their action being assisted by contraction and 
depression of the ventricular bands. In high tones the arytenoids 
were seen to be forcibly drawn up under the epiglottis. A similar 
mechanism was found in the case of a professional ventriloquist in 
producing the primary ventriloquial tones, although he could not 
make a laryngeal whistle. The explanation here offered was con- 
firmed by Elsberg in two cases of his own, and several other exam- 
ples of this curious phenomenon are quoted. A different explanation 
is given by G. Hudson Makuen, and it may be that the feat of laryn- 
geal whistling is capable of performance in various ways. He had 
an excellent opportunity to study the condition in the case of a young 
man who could whistle a tune with his mouth open. He found and 
was able to demonstrate to others that the aryepiglottic folds were 
pursed up precisely as the mouth is in whistling and that no other 
part of the larynx was used, the vocal bands having no more share 
in the laryngeal whistle than in the ordinary lip whistle. In still 
another case reported by C. E. Munger the ventricular bands seemed 
to be chiefly concerned, space for the air blast being left at the pos- 
terior fourth of the vocal bands which were elsewhere in firm con- 
tact. 

PARALYSIS OF THE LARYNX. 

Interference with the action of the laryngeal muscles may be of 
myopathic origin or referable to some lesion of the nervous system, 
either central or of one of the laryngeal nerves in continuity. A 
typical example of the former may be seen in the aphonia occurring 
in tubercular laryngitis, due, in part, to mechanical interference with 
muscular movements by infiltration at the posterior commissure, and, 
in part, to a general muscular atony. 

A very common form of myopathic paralysis is seen in tin- loss of 



400 



DISEASES OF THE NOSE AND THROAT. 



power of the thyroarytenoid muscles resulting from overuse of the 
larynx when inflamed. Vocal fatigue from muscular strain, whether 
in speaking or singing, often results in this condition. The thyro- 
arytenoid muscles are the most important and interesting of the in- 
trinsic muscles of the larynx as regards purity and sweetness of tone. 
Some of their fibers are distributed to the margin of the cord and 
are capable of limiting vibration to one portion of the vocal band. It 
is easy then to appreciate how inflammation of the bands may inter- 
fere with their delicate mechanism. Impairment of the action of 
these muscles produces very marked alteration in timbre and range 
of the voice, which is weakened and may be altogether lost. The 
laryngoscopy picture is perfectly characteristic and unmistakable. 
Instead of a close approximation of the cords an elliptic opening from 




Fig. 136. Bilateral Paralysis of 
Internal Thyroarytenoids. 




Fig. 137. Paralysis of Arytexoideus. 



the vocal process to the anterior commissure remains on attempts at 
phonation. A similar picture is presented, only to a more marked 
degree, when the cricothyroid muscle is paralyzed (Fig. 136). 

The arytenoideus muscle may be affected in case of lesions of the 
superior laryngeal nerve which, at the same time, involve the crico- 
thyroid muscle, when in addition to the elliptical opening between the 
bands anteriorly, a triangular opening exists at the posterior part of 
the rima glottidis, the only portions of the vocal bands in contact 
being the vocal processes (Fig. 137). 

This muscle may also suffer in connection with a chronic catarrhal 
laryngitis, in incipient tubercular disease, in diphtheria and in hys- 
teria. The voice may be hoarse, feeble, or entirely lost, attempts at 
phonation being very tiresome owing to waste of air in the expira- 
tory blast ( Fig. 138). 



PARALYSIS OF THE LARYNX. 4OI 

Bilateral paralysis of the lateral cricoarytenoids is a very rare con- 
dition. The laryngeal image is almost identical with that of bilateral 
paralysis of the recurrent laryngeal nerve. It may result from lead- 
poisoning, diphtheria, or from one of the exanthemata. 

Unilateral paralysis is also very infrequent and is due to causes 
similar to those just mentioned. It is characterized by impaired 
rather than complete loss of voice, the unaffected cord attempting to 
compensate for the paralysis of the opposite cord by crossing the 




Fig. 138. Paralysis of Internal Thyroarytenoids and of Arytenoideus. 

middle line, the arytenoid cartilage on the sound side passing in front 
of the opposite arytenoid. 

The prognosis, in all these forms of paralysis, is, as a rule, favor- 
able provided we can place the patient under proper conditions. 

The first indication in all is to secure rest for the larynx; in the 
second place, to remove the cause of the affection if it can be dis- 
covered. Electricity, by means of faradism or galvanism, may be 
used every day for ten or fifteen minutes, one electrode being placed 
within the larynx, the other externally. The general health should 
receive attention and the use of tonics, exercise, full diet and strych- 
nia to its physiological effect, will assist recovery. 

The most common form of paralysis of the vocal bands due to nerve 
lesion is recurrent laryngeal paralysis, which may be traced, in a large 
proportion of cases, to pressure upon the recurrent laryngeal nerve 
at the root of the neck, generally by aneurism of the arch of the 
aorta, or by enlarged lymphatic glands, mediastinal tumors, or eso- 
phageal growths, or by pleuritic adhesions at the apex of the lungs 
in tuberculosis. The last mentioned cause is met with more fre- 
quently upon the right side than upon the left. A central lesion from 
cerebral apoplexy, embolism, or occurring in the course of locomotor 
26 



402 DISEASES OF THE NOSE AND THROAT. 

ataxia, may lead to similar phenomena. The neuritis following diph- 
theria or typhoid fever may also result in paralysis of the inferior 
laryngeal nerve. In this condition the cord affected assumes the 
cadaveric position midway between abduction and adduction, the apex 
of the arytenoid being tilted forward. The unaffected cord crosses 
the middle line in phonation to meet the opposite cord, the sound 
arytenoid passing in front of the paralyzed arytenoid, giving a very 
distorted laryngeal picture. The loss of voice is usually not very 




Fig. 139. Partial Paralysis of Right Recurrent during Respiration. 

marked, complete aphonia being the rule only when both recurrent 
nerves are affected. Paralysis of one nerve usually develops slowly 
and, as it progresses, the opposite cord has time to compensate for the 
loss of action on the part of the paretic vocal band (Fig. 139). 

The prognosis of recurrent laryngeal paralysis depends upon the 
location of the disease and upon its duration. \Yhen it has existed 



-€►- 



Fig. 140. Partial Paralysis of Right Recurrent during Phonation. 

for many months degenerative changes may have occurred in the 
muscles which cannot be overcome (Fig. 140). 

The treatment should be governed by the nature of the cause of 
the affection. Post-diphtheritic cases recover under tonic doses of 
strychnia and the use of electricity. These methods, of course, 
should not be used in cases of paralysis due to aneurism or to pres- 



PARALYSIS OF THE LARYNX. 4O3 

sure upon the trunk of the nerve, although there is no objection to 
exercising the intrinsic muscles of the larynx by means of the faradic 
current if there is any hope that the function of the nerve may be 
eventually restored (Fig. 141). 

A lesion of the superior laryngeal nerve results in complete anes- 
thesia of the laryngeal mucosa as well as in paralysis of the crico- 
thyroid and occasionally in paresis of the arytenoideus, in some cases 
the superior laryngeal nerve sending a few motor fibers to the latter 
muscle. The loss of sensation is sometimes an important feature 
necessitating artificial feeding, since anesthesia of the larynx may lead 
to inspiration of particles of food which would not be promptly re- 
jected. 

The laryngeal picture has been referred to in speaking of paralysis 
of the arytenoideus muscle, the only parts of the vocal bands in con- 




Fig. 141. Complete Right Recurrent Paralysis on Phonation. 

tact being the vocal processes, an elliptical opening remaining ante- 
riorly and a triangular opening posteriorly during phonation. A 
large proportion of these cases result from diphtheria. 

Recovery may be spontaneous in the course of a few months or may 
be deferred a year or more, but it may be expedited by judicious 
treatment, counter-irritation, stimulation with electricity, massage 
and tonics. In this, as in most other forms of paralysis, care should 
be taken to avoid overuse of the voice and all intercurrent inflam- 
matory conditions should receive attention. 

Paralysis of the abductors, or posterior cricoarytenoid muscles, 
may be bilateral or unilateral. The most frequent cause of bilateral 
abductor paralysis is a syphilitic lesion involving the special nerve 
center. It may occur in locomotor ataxia. Again, it may be due to 
lesions in the course of the nerve, such as neoplasm, aneunaiii, or 



404 DISEASES OE THE NOSE AND THROAT. 

goitre. It may occur in lead-poisoning and is said to follow toxemia 
from various other chemical poisons (Fig. 142). 

The dyspnea resulting from this condition comes on by degrees 
and is inspiratory. It is distinctly progressive, is aggravated by 
exertion or excitement and may become at any moment of serious 
import. Expiration is usually unaffected and the voice is unchanged 
except, perhaps, being slightly weaker than normal. 

In the mirror, the image on phonation is unaltered ; but, during 
respiration, the cords are seen lying near together in the middle line 
instead of being abducted. 

The treatment will depend upon the cause discovered. If of syph- 
ilitic origin the disorder may frequently be remedied by the adminis- 




Fig. 142. Partial Paralysis of Posterior Cricoarytenoids during Respiration. 

tration of iodide of potassium, pushed to its fullest extent, at the same 
time, the muscular tone being preserved by means of electricity. 
The possibility of sudden laryngeal stenosis should be kept in mind 
and the probable necessity of intubation or tracheotomy. The latter 
seems to be preferred. In a case of my own in which the paralysis 
followed extirpation of a goitre, an intubation tube was worn for a 
short time but became so irksome to the patient that she insisted upon 
the trachea tube being introduced. The obvious advantage of the 
latter is that with the trachea tube in situ the patient is still able to 
phonate, which is not the case with an intubation tube. It has been 
proposed in inveterate cases of bilateral abductor paralysis to split the 
larynx and excise the paralyzed cords, a radical mode of treatment 
which has not received universal acceptance. Section of the recur- 
rent laryngeal nerves which would result in placing the cords in the 
cadaveric position and, at the same time, abolish the voice, has been 
suggested by Krause. Section of the nerve of one side only might 
give adequate breathing space without destroying the voice. 



PARALYSIS OF THE LARYNX. 4O5 

Unilateral paralysis of the abductors may be due to causes similar 
to those acting in the case of bilateral paralysis, except that it has 
never been known to follow a central lesion, but the former is by no 
means a condition of equal seriousness. The voice is preserved and 
nothing anomalous is to be seen in the mirror during phonation, but 
on inspiration the affected cord occupies the middle line, while the 
sound cord is abducted in a normal way. Active treatment is seldom 
called for, except in syphilis, since the symptoms are usually unim-. 
portant. 

The preponderance of abductor over adductor paralysis has led to 
the enunciation by Felix Semon of a law ascribing to the posterior 
cricoarytenoid muscles, the only abductors of the vocal bands, an es- 
pecial vulnerability, in consequence of which adduction of the cords is 
the phenomenon first noticed in general laryngeal paralysis. The 
question has been hotly discussed. Recent investigations by Gross- 
man seem to show that after division of the recurrent nerve the vocal 
bands assume a median position for a few hours or days, as the case 
may be, gradually becoming cadaveric. The primary position in 
adduction he explains by temporary action of the cricothyroid and 
the external muscles which, of course, are not affected by abolition of 
the function of the inferior laryngeal nerve. This view, however, 
drawn from experiments on the cat, is opposed by the best authorities, 
who find that in human beings the bands at once become cadaveric 
on section of the recurrent. A possible explanation of a posticus 
vulnerability may be found, as suggested by Grabower, in a peculiar 
difference in the way in which the nerve terminates in the abductors 
and in the adductors, in the latter its endings being broader and 
firmer. Hence we might expect the innervation of the adductors to 
be more vigorous and resistant than that of the abductors. What- 
ever explanation of the fact may be offered the majority of observers 
seem to agree that under electrical stimulation the laryngeal adductors 
exhibit more vitality than the abductors. In studying the innerva- 
tion of the larynx confusion is apt to arise from the fact that the 
nerves of either side may cross to supply the muscles of the opposite 
side. Moreover many observations have established the fact that 
motor fibers from the superior laryngeal nerve sometimes pass to the 
adductor muscles. The whole question is so intricate and opportuni- 



406 DISEASES OF THE NOSE AND THROAT. 

ties for observing paralysis of the larynx are so rare that a final 
solution of the problem has not been reached. 

In relation to the question of laryngeal paralysis it may be of 
service to keep in mind the following propositions. 

i. All the intrinsic muscles of the larynx are attached to the aryte- 
noid cartilages, except the cricothyroid. 

2. The cricothyroid arises from the thyroid cartilage and is in- 
serted into the cricoid, hence in contracting it pulls up the anterior 
border of the latter, tilts the arytenoids backwards and makes tense 
the vocal bands, in the meantime the thyroid cartilage being immova- 
bly fixed by the action of the external muscles, the sternothyroid and 
the thyrohyoid. 

3. The superior laryngeal nerve is the sensory nerve of the larynx, 
but sends motor fibers to the cricothyroid muscle and sometimes to 
the arytenoideus. 

4. The inferior, or recurrent, laryngeal nerve gives motor fibers to 
all the intrinsic muscles, except the cricothyroid. 

5. Nerve fibers in the vagus supplying antagonistic muscles run in 
separate bundles throughout the length of the recurrent nerve. 

6. Adjacent cortical centers at the lower end of the ascending 
frontal convolution exist for both the adductors and the abductors 
and are bilateral in action. Hence bilateral spasm of the larynx fol- 
lows irritation of the cortical center of either side, that of the adduc- 
tors predominating because of the greater strength of these muscles. 

Owing also to the bilateral action of the cortical centers laryngeal 
paralysis never results from a unilateral lesion. 

7. In progressive disease affecting the innervation of the larynx 
the abductors are the first to succumb to paralysis and atrophy. If 
recovery takes place the reverse course is pursued and the adductors 
are first to regain tone. 

8. In complete recurrent paralysis the vocal bands at once assume 
a cadaveric position, midway between adduction and abduction. 

It is desirable but often quite impossible to differentiate between 
paralysis of the vocal bands and anchylosis of the cricoarytenoid artic- 
ulation. Disturbance in the joint may follow exposure to cold, infec- 
tion, rheumatism, tuberculosis, or traumatism. A feeling of discom- 
fort or of slight pain on swallowing or when lying down may be 



PARALYSIS OF THE LARYNX. 407 

complained of. It is difficult for the patient to locate the sensation 
but it may be defined by palpation over the cricoid in the neighbor- 
hood of the joint. The pain is to be distinguished from that present 
in an aggravated degree of hyperesthesia of the superior laryngeal 
nerve by the fact, affirmed by Griinwald, that in the latter pressure 
must be applied at " the upper lateral border of the thyroid at its 
center." In some cases crepitation may be detected. In the laryngeal 
mirror nothing abnormal may be seen until periarthritic swelling 
supervenes, or the movement of the vocal band on the affected side, 
instead of being smooth and gliding, is uneven and jerky. The excur- 
sion of the band on attempts at phonation may be incomplete or 
entirely absent. If the band is fixed in a position simulating that of 
one of the forms of paralysis it may be possible to make a diagnosis 
only by excluding the probable causes of disturbed innervation. In 
most cases of anchylosis there is more or less permanent thickening 
about the joint, which of course is not a feature of paralysis. A 
position of a vocal band unlike that of a neurosis, that is, neither 
in adduction, abduction, nor cadaveric, a jerky movement of the band 
on phonatory efforts, and finally variable motility, or in other words 
more freedom of motion at one time than at another, are presump- 
tive evidence of cricoarytenoid arthritis. The case is strengthened 
by a distinct history of rheumatism, of syphilis, or of tuberculosis. 
The greatest difficulty arises in connection with cases of complete 
fixation of the crico-arytenoid joint without thickening. A most 
important point, especially noted by Watson Williams, is the relation 
to each other of the arytenoids. Their relative positions in paralysis 
have been described : in anchylosis the sound arytenoid on phonation 
does not cross the crippled one, pushing it aside, but merely crowds 
up against it without displacing it. In certain old cases of paralysis 
the joint may become anchylosed from disuse, so that the point last 
mentioned is not invariablv reliable. 



CHAPTER XXIV. 

FOREIGN BODIES IX THE LARYNX. PROLAPSE OF THE VENTRICLE. 

FRACTURE OF THE LARYNX. 

FORETGX BODIES IN THE LARYNX. 

The subject of foreign bodies in the larynx carries the laryngologist 
somewhat beyond the limits of his territory, since in many cases a 
body supposed to have entered the larynx is found not in that cavity, 
but in the pharynx, the trachea, or a bronchus. It will be conve- 
nient, therefore, not to confine this consideration strictly to the larynx. 
The importance of a foreign body in the larynx depends upon the 
shape and size of the object and upon its point of lodgment. Fatal 
asphyxia may follow the inspiration of a very large body, whereas 
a small sharp-pointed object, like a fish-bone, pin, or piece of glass, 
may not interfere seriously with the air current. An object with 
rough, irregular surfaces is much more apt to be caught in the laryn- 
geal cavity than one with a smooth surface. A glass bead, for exam- 
ple, is likely to slip through the glottis, lodge in a bronchus and 
become the source of very serious mischief. A case which attracted 
great attention several years ago was that of a well-known clergyman 
who inhaled a cork he was holding between his teeth (Rushmore). 
The body passed directly through the larynx and lodged in a bron- 
chus. Efforts to remove it through an opening in the trachea were 
unsuccessful and death from pneumonia finally ensued. The feasi- 
bility of reaching the foreign body in cases of this kind by a bron- 
chotomv done from behind has been suggested. Almost any object 
that the mouth can hold is liable to be drawn into or towards the 
glottis so as to impede respiration. Children particularly have a 
fashion of putting everything in the month ; whence, in deep inspira- 
tions preceding laughing or coughing there is danger of the foreign 
body being sucked into the lower air-track. 

Usually the signs of invasion of the larynx by a foreign body are 
unmistakable; but, it is remarkable that one, even of large dimen- 

408 



FOREIGN BODIES IN THE LARYNX. 409 

sions, under some circumstances, may be retained for a considerable 
time without producing much disturbance. Several years ago I 
reported a case of tooth-plate, which fell into the larynx during a 
puerperal convulsion and was not discovered until one week later 
when the patient complained of sore throat. Lennox Browne, a few 
years ago, recorded a case in which a plate of artificial teeth was 
impacted in the larynx twenty-two months before it was recognized. 
S. W. Langmaid once removed a pin from the larynx two years 
after it had been inhaled, in the meantime hoarseness being the only 
symptom. Johnston's famous case of a toy locomotive, impacted in 
the larynx and removed several months after a tracheotomy for relief 
of the immediate symptoms, is probably unique. 

In a large proportion of cases collected by Durham spontaneous 
expulsion took place in from one to seventeen years, and Gross 
records a case in which a piece of bone was retained in the air pas- 
sages for more than sixty years. Cameron's case of a penny in the 
larynx for six years, and Cohen's two remarkable cases in which a 
foreign body, one of them a pebble stone, remained in the air-track 
for ten years without doing much damage, are noteworthy. 

In striking contrast to the tolerance displayed in cases like those 
just mentioned is the violent and prolonged spasm often excited by 
a drop of water or a crumb of bread which may barely get into the 
larynx in that unpleasant phenomenon known as " swallowing the 
wrong way." Occlusion of the trachea has been known to follow the 
escape of caseous material from an ulcerating bronchial gland, and 
vomited matter not infrequently finds its way into the larynx, espe- 
cially in the newborn, in weaklings, in alcoholics and during anaes- 
thesia. Numerous instances of lumbricoids in the larynx, many of 
them fatal, have been recorded, and the introduction of leeches in 
drinking water seems to be a not uncommon accident in certain coun- 
tries. A single instance in which the tip of the epiglottis curled back 
and became engaged in the rima glottidis so as to induce dangerous 
symptoms has been recorded by Ruehle. Cases in which an elon- 
gated uvula has not only irritated the larynx but caused serious em- 
barrassment to breathing have come under my observation. In one in 
particular the patient was supposed to have edema of the glottis. 
Several cases in which the fragment of a broken dental or surgical 



4IO DISEASES OF THE NOSE AND THROAT. 

instrument has fallen into the larynx have been reported, and no less 
than twenty examples of broken or corroded trachea tubes dropping 
into the windpipe are to be found in literature. 

The first symptom excited by a foreign body in the larynx is a 
paroxysm of coughing which, in some cases, is successful in expel- 
ling the intruder. Spasmodic contraction of the muscles in violent 
efforts at coughing may, on the other hand, drive a sharp-pointed 
body into the wall of the larynx where it will remain until removed 
by artificial means. Hemorrhage may be excited by a body of this 
character. Bosworth narrates an unusual case in which repeated 
attacks of hemoptysis were apparently caused by a calcareous mass 
resembling a tooth lodged in a bronchus without giving any physical 
signs. The bleedings ceased after the foreign body had been expelled 
by coughing. In all cases in which the accident is suspected attempts 
at laryngeal examination should be made but, owing to the perturba- 
tion of the patient, it is often impossible to get any view. Under 
these circumstances it often happens that a mistaken diagnosis is the 
result. The symptoms have been attributed, in some cases, to croup 
or whooping-cough. In a very extraordinary case referred to by 
DeForest Willard a tracheotomy was done and prolonged search 
made for an article afterwards found in the child's pocket, certain 
lung symptoms which were present being due to a pneumonia devel- 
oping from ordinary causes. 

In a case of my own in which the voice was lost and no other 
symptom was present after the first disturbance the electric current 
was applied to the larynx for more than a week with the hope of 
restoring the lost vocal function ; at the end of that time a laryngeal 
examination discovered, lodged in the ventricle of the larynx near 
the anterior commissure, a shoe-hook. Six weeks later the boy was 
brought to my clinic where, after several ineffectual efforts at extrac- 
tion through the mouth, I performed partial laryngo-fissure and 
removed the hook. Recovery was complete and, in the course 
of six w r eeks, perfect use of the voice was regained. It is claimed 
that Kirstein's method of examining the larynx in children under 
these circumstances, is particularly successful. My own experience 
in the case just detailed was not satisfactory. Quite recently an 
almost identical case has been reported by E. Fletcher Ingals, but 



FOREIGN BODIES IN THE LARYNX. 



411 



in the latter the foreign body was pushed upwards by means of a 
Trousseau tracheal forceps and then extracted with the finger passed 
into the mouth. 

In every case, unless the symptoms be urgent, in which the pres- 
ence of a foreign body in the air-track is suspected a careful laryngo- 
scopy examination should be made before attempts at removal are 
undertaken. In many cases a tracheotomy for relief of dyspnea must 
be done at once, and an examination made later. The precise loca- 
tion of a foreign body may be defined by means of the Roentgen 
rays when it cannot be discovered by inspection. Little or no reliance 
should be placed on the statement of a patient as to its situation, since 
subjective sensations are altogether misleading. It is a very com- 
mon experience for a patient to point with confidence to the exact 
spot, where nothing can be detected except slight redness, or perhaps 
an abrasion or scratch made in transit by a foreign body which has 
been swallowed. These imaginary foreign bodies comprise a very 
large proportion of those which the surgeon is called upon to remove. 
On the contrary, a pin or a small fish-bone may become embedded 
in a lymph follicle at the base of the tongue, or in a tonsillar crypt, 
where it may readily elude a superficial search. Here the use of a 
probe to push aside folds of mucous membrane is often of service. 
Rough palpation with the finger is unwise, because a sharp object 
may be pushed still further into the tissues, or a movable one may 
be dislodged and fall into the larynx. 

The management of foreign bodies in the larynx demands the 
exercise of great ingenuity and dexterity. As examples of clever 
devices employed for their removal may be mentioned the electro- 
magnet in the case of metallic articles (Voltolini, Garel and Goul- 
lioud), a sponge after Voltolini's method (Max Thorner) and cotton 
wool wound on the end of the finger (Crawley) in the case of a 
cockle-burr in the larynx, and finally a brush dipped in mucilage to 
extract a thread (Brandeis). When the stenosis is due to spasm 
rather than to the volume of the object the inhalation of chloroform 
or the local use of cocaine may be of advantage. An impacted body 
which interferes but slightly with breathing may be dealt with some- 
what deliberately. A smooth movable body is more dangerous 
because of its liability to shift its position and fall into a bronchus. 



412 DISEASES OF THE NOSE AND THROAT. 

A sharp-pointed or angular body, if roughly handled, may damage 
the wall of the larynx excessively, may even cause emphysema of the 
cellular tissue, or induce hemorrhage by penetrating a blood-vessel. 
It is sometimes necessary to break up and remove piecemeal an irreg- 
ular object. A pin, lying in the larynx with point upwards, must. If 
possible, be seized and pushed downwards before any attempt should 
be made to withdraw it. In adults, as a rule, the manipulations may 
be conducted under local anesthesia with cocaine. In children, gen- 
eral anesthesia will, not infrequently, be demanded. In young sub- 
jects, the interior of the larynx may often be reached by the tip of 
the finger. If the body is seated high up it may be removed by 
hooking the finger beneath it. In other cases we have to choose one of 
the various laryngeal forceps. Mackenzie's or Cusco's (Fig. 143), 




Cusco's Laryngeal Forceps. 



or if preferred tube-forceps, or the cold-wire snare may be selected 
according to circumstances. If it become apparent that an unwar- 
rantable amount of force may be needed to dislodge an impacted 
body the alternative of external operation is presented. In the latter 
case we should hold before us the importance of preserving the func- 
tion of the larynx by accurate replacement of the vocal bands, an 
object not easy of accomplishment if section of the thyroid cartilage 
has been complete. To secure perfect apposition of the halves of the 
larynx it is well, therefore, to leave the upper margin of the cartilage 
undivided. This mode of procedure, especially in young subjects in 
whom the parts are pliable, does not interfere with a satisfactory 
exposure of the interior of the larynx. In order to prevent reflex 
inhibition of heart action applications of cocaine to the mucous mem- 



FOREIGN BODIES IN THE LARYNX. 413 

brane both before and during a fissure of the larynx are recom- 
mended, and great care should be taken to keep the incisions in the 
middle line. 

The use of emetics and experiments with inversion in children 
should not be resorted to unless we are prepared to open the trachea, 
since the foreign body may be propelled from below to a position in 
which it may completely block up the lumen of the larynx. This 
especially applies to a body known to be jagged or irregular in con- 
tour, and if it has passed beyond the larynx Weist advises never to 
try inversion without a preliminary tracheotomy. If the trachea must 
be opened it is well to enter at as low a point as possible, to make a 
long incision and possibly to resect a part of two or more tracheal 
rings in order to provide for easy exit of the foreign body in case it 
should be dislodged by coughing. The method of inversion proposed 
by Padley seems to be applicable to adults and comparatively free 
from danger. The patient is made to lie on his back with his knees 
flexed over the end of a bench which is considerably higher than the 
opposite end. He should inspire deeply and not attempt to speak. 
Forcible concussion of the chest sometimes helps to dislodge the 
foreign body. The supine position favors its escape and should it 
impinge upon the chink of the glottis the patient is readily able to 
resume the upright posture. In Roe's collection of seven hundred 
and sixty-three cases of foreign bodies in the air-passages we find 
only three relieved by inversion and six by emesis when the larynx 
was involved, while nine recovered after inversion and two after the 
use of emetics when the substance was in the trachea. From an 
analysis of the combined statistics of Weist (one thousand cases), 
Durham (seven hundred and six cases), Gross (one hundred and 
eighty-three cases), and his own. Roe concludes that a foreign body 
should not be allowed to remain in the air-passages for any length 
of time without operation in case attempts at extraction by other 
means have failed. When the larynx is occluded by a large foreign 
body, or by the spasm its presence excites, the trachea should be 
opened without delay, though the patient appears to be moribund or 
even dead. The discouraging opinion attributed to Louis that in 
cases of this kind we are helpless because no interval exists between 
perfect health and death seems to be unfounded, in view of the success 



414 DISEASES OF THE NOSE AND THROAT. 

attending- artificial respiration and similar restorative measures in 
analogous conditions. A rapid tracheotomy followed by judicious 
and prolonged artificial respiration will sometimes save a case appar- 
ently desperate. Coins and flat objects that are apt to take a trans- 
verse position in the larynx are conveniently reached with Watson 
William's forceps. A coin in the esophagus has several times been 
successfully extracted with Smith's coin-catcher. Opposite the cri- 
coid, the narrowest part of the gullet, a foreign body is most likely to 
be arrested. Coolidge once removed a foreign body from the right 
bronchus by passing an alligator forceps along a urethroscope which 
had been introduced through a tracheotomy wound. The gradual 
solution of fish bones by means of vinegar and of meat bones by a 
dilute solution (one to five per cent.) of hydrochloric acid has been 
suggested. A fish hook with its barbed point embedded in the tissues 
would seem to be almost impossible of removal by any internal 
method, but Christison's scheme of threading the wire attached to 
the hook through a hole drilled in the ball of a probang was highly 
successful in one case. Fortunately the wire had not been swallowed 
and it served as a guide to the bulb of the probang which latter so 
dilated the walls of the esophagus as to loosen the points of the hook 
and allow it to be withdrawn without catching. In the larynx a sim- 
ilar plan would not be feasible and an external operation would be 
the only alternative, either a subhyoid pharyngotomy or a laryn- 
gotomy. In a recent case in my clinic at Cornell Medical College a 
metallic heel plate was removed by Mack from the laryngopharynx 
of a shoemaker who was in the habit of holding these objects in his 
mouth while at work. Three sharp prongs projecting from the sur- 
face of the plate had to be disengaged by pressure with the finger, in 
the meantime traction being made on the plate which had been seized 
with canula forceps. Very little reaction followed, although the plate 
had been in the pharynx eight or ten hours, and had excited almost 
constant and irresistible desire to swallow. 

It is seen, therefore, that almost every case of foreign body in the 
larynx, or in neighboring regions, presents features peculiar to itself 
which must be met according to circumstances. 



FOREIGN BODIES IN THE LARYNX. 415 

PROLAPSE OF THE VENTRICLE OF THE LARYNX. 

Prolapse of the ventricle of Morgagni is a rare condition, very apt 
to be confounded with a new growth or with a simple inflammatory 
hyperplasia. It consists of protrusion of the sacculus laryngis as a 
result of sudden voice-strain or violent coughing, possibly in con- 
junction with atomy or paresis of the muscle known as the com- 
pressor sacculi laryngis, or Hilton's muscle. In one case in my ex- 
perience a protruding mass simulating prolapse of the ventricle was 
excised, when it proved to be a tubercular infiltration. Serious doubt 
as to the possibility of eversion of the ventricle was suggested long 
ago by Fraenkel and by Chiari. Moure believes that the condition 
of apparent prolapse is really one of chronic inflammation, and this 
view has received recent confirmation by Noack, who found that the 
tissues of a supposed everted ventricle were composed of vascular 
and edematous hypertrophies. It is maintained by Schroetter that 
an apparently prolapsed ventricle is in reality an example of chronic 
subglottic laryngitis, the thickened and projecting tissues giving the 
misleading impression of a tumor which seems to spring from the 
site of the ventricle. 

The treatment consists simply in replacement of the ventricle by 
means of a laryngeal probe and of faradization of the muscles of the 
larynx together with prohibition of the use of the voice for a consid- 
erable period. It may be found impossible to restore the prolapsed 
sacculus, in which case ablation would be the proper procedure, pro- 
vided the subjective symptoms are very pronounced. 

FRACTURE OF THE LARYNX. 

Fracture of the larynx is a rare accident and may result from direct 
violence, as from a blow or by choking, from bullet wounds, or from 
muscular action during a violent paroxysm of coughing (Sajous). 
A large proportion of cases have been observed in early life, so that 
ossification of the cartilages incident to old age cannot be regarded as 
a predisposing factor. 

In most cases the thyroid alone is fractured, but in many the cricoid 
also is involved and in a few the hvoid bone is broken. 



4l6 DISEASES OF THE NOSE AND THROAT. 

External deformity is at once quite marked either as a depression 
or an unusual prominence of the thyroid, accompanied by more or 
less swelling of the external soft parts. If the mucous lining of the 
air-track is lacerated hemorrhage may occur, and aphonia and cough 
with blood-streaked sputa are prominent symptoms. Dyspnea may 
be present early or not for several days after the accident. Emphy- 
sema may be limited to the neighborhood of the injury or may be 
diffused over the whole body, as in the case of a child six years old 
reported by Hume. The foregoing symptoms, together with crepita- 
tion on palpation, should establish the diagnosis. In severe cases 
when the cartilage is comminuted or the fracture is compound, but 
little doubt can exist. In simple cracks or linear fractures there may 
be more difficulty. The prognosis in cases of the latter class is favor- 
able. A penetrating wound over the thyroid cartilage may be dem- 
onstrated by blood-stained sputum and impairment of voice, the latter 
remaining permanent. 

In treatment the first indications are to replace distorted fragments 
and control inflammatory reaction by cold affusions. Swelling and 
edema may necessitate a tracheotomy or intubation. The latter is 
preferable, both with a view to supporting depressed fragments of 
cartilage and to preventing contraction of the air-tube during the 
process of repair. An O'Dwyer intubation tube as large as the 
larynx will accommodate should be selected and its introduction may 
be facilitated by preliminary spraying with cocaine and suprarenal 
extract. In a case reported by W. K. Simpson a very large, some- 
what conical, tube was used which served as a dilator as well as an 
air-tube. In cases of extensive damage an intubation tube does not 
reach far enough and the only alternative is an opening in the trachea 
at the lowest possible point. 



INDEX. 



Abscess of nasal septum, 140 

retropharyngeal, 263 

of tongue, 262 

of tonsil, 276 
Absolute alcohol in laryngeal neo- 
plasms, 344 
Accessory sinuses, 24 
disease of, 73 
in hay fever, 192 

thyroid tumors, 262 
Adenectomy, accidents in, 237 

anesthesia in, 230 
Adenoids, 222 

facies of, 227 

and laryngeal neoplasms, 225 

recurrence of, 238 
Adhesions, intranasal, 143 
Adrenalin, 174 

Allen, C. W., on rhinoscleroma, 186 
Amygdalotomy, 248 
Amygdalothripsis, 250 
Anchylosis of cricoarytenoid joint, 406 
Angina of Vincent, 283 
Anosmia, 25, 188. 
Antrum, anomalies of, 81 

asymmetry of, 81 

Caldwell-Luc operation for em- 
pyema of, 87 

cyst of, 81, 109 

foreign bodies in, 87, 11 1 

neoplasms of, 11 1 

polypi of, no 

transillumination of, 80 
Aphonia, hysterical, 393 
Aprosexia, 226 

Aronsohn on primary laryngeal tuber- 
culosis, 363 
Arytenoids, clubbing of, in tuber- 
culosis, 367 
Arteries of the nasal mucous mem- 
brane, 23 
Asch's operation for deviated septum, 

128 
Atrophic rhinitis, 61 
Autoscopy, 317 



B 



Bands, ventricular, 310 
vocal, 312 

27 



Bates, W. H., on suprarenal extract 

solution, 174 
Bernays' cotton sponge, 59, 173 
Bifid uvula, 208 

Bishop, S. S., on hay fever, 192 
Birkett's double transluminator, 91 
Bliss, A. A., on Allen's operation for 
deviated septum, 125 
on hemorrhage after adenectomy, 
236 
Bodies, foreign in air track, 409 
Bone changes in nasal polypi, 151 
Bosworth on laryngeal spasm, 398 

on neuralgia of the larynx, 392 
Boylan, J. E., on a method of ablating 

nasal hypertrophies, 50 
Brady, A. J., on a case of angioma of 

the larynx, 339 
Brindel on paraffin in nasal atrophy, 67 
Browne, Lennox, on malignant trans- 
formation of benign growths, 162 
Bryan, J. H., on acute sinusitis, 77 

on the antrum as a reservoir for 

pus, 83 
on probing the sphenoidal sinus, 
105 
Bulla ethmoidalis, 21 
Butlin, H. T., on cancer of nose, 166 
on explorative laryngo fissure, 361 



Cancer of larynx, 351 

of nose, 165 
Capart on the treatment of singers' 

nodes, 329 
Casselberry on a case of edema of the 

glottis, 324 
Catarrhal diathesis, 37 
Cerebrospinal rhinorrhea, 198 
Champeaux on adenoid facies, 227 
Chappell, W. F., on conditions resem- 
bling adenoids, 227 
on hemorrhage from circumtonsil- 
lar abscess, 279 
Charcot on laryngeal vertigo, 304 
Cheyne, Watson, on laryngectomy, 359 
Chorditis tuberosa of Tiirck, 326 
Chorditis vocalis inferior of Gerhardt, 

330 
Chorea laryngis, 395 



417 



4i8 



Circumtonsillar abscess, 276 

hemorrhage from, 279 

Clark's solution for hay fever, 194 

Clark. Payson, on a case of cyst of the 
larynx, 336 

Cleft palate, 210 

Coakley, C. G., on recurrence of ex- 
cised tonsils, 256 

Coates, George, on epistaxis in the 
aged, 169 

Cobb, F. C., splint for fractured nose, 
147 

Coley's toxin treatment of sarcoma, 112 

Collapse of nostril, 144 

Columnar cartilage, dislocation of. 145 

Comstock, A. B., on subcutaneous use 
of paraffin, 180 

Concha bullosa. 45 
suprema, 20 

Congenital occlusion of nares, 142 

Corning. T. L., on subcutaneous injec- 
tion of solidifying oils. 180 

Coryza. 36 

Crile, Geo., on cocaine in adenectomy, 
230 

Cupric electrolysis in atrophy, 69 

Curtis, Holbrook, on hay fever, 195 

Cyst of larynx, 116 
of nose, 160 
of pillar of fauces, 206 
of turbinate, 44 



Daly, W. H., on a splint for fractured 

nose, 147 
Darmack packer. 172 
Dawbarn's purse string ligature for 

tonsillar hemorrhage, 253 
Delavan, D. B., on galvanism in 
atrophy, 69 

on laryngectomy, 359 

on X-ray therapy for cancer, 362 
Dentary cysts, 81 
Deviated septum, Asch's operation, 128 

Harrison Allen's operation, 124 

Gleason's operation, 132 

Ingals' operation, 125 

Krieg's window resection opera- 
tion, 126 

Kyle's operation, 123 

Moure's operation, 121 

Roberts' operation, 119 

Roe's operation, 119 

Watson's operation, 133 
Diphtheria. 273 
Diphtheroid angina, 283 
Discission of tonsillar abscess, 282 
Dislocation of columnar cartilage, 145 
Dobell's solution, 47 



Douglas, Beaman. on emphysema of 
eyelid with ethmoid disease, 
100 
on supplementary cells in 
sphenoidal wings, 106 

Duct of Stenson, 22 



Edema glottidis, 323 

Electric cautery in nasal hypertrophy, 

53 
Electrolysis in septal spurs. 138 
Emphysema of eyelid in ethmoid dis- 
ease, 100 
Empyema of antrum, 76 
Epiglottis, function of, 312 
Epistaxis, 168 

Ethmoid cells, disease of, 99 
Ethmoiditis and ozena, 100 
Examination, digital, of nasopharynx, 
35 

F 
Ferrier's snuff, 38 
Fibroma of larynx, 335 
of nasopharynx, 159 
of nose, 158 
Fink, E., on hay fever, 192 
Foreign bodies in larynx, 409 
in nose, 166 
in pharynx, 300 
Fossa innominata, 310 
Fowler, W., on cricoarytenoid arthritis 

in tuberculosis. 367 
Fracture of larynx, 416 

of nose. 146 
Fraenkel. B., endolaryngeal treatment 

of carcinoma, 357 
Freer, Otto, on operation for deviated 

septum, 126 
French, T. R., position of patient in 

adenectomy, 232 
Freudenthal, W., on rhinoscleroma, 186 
Freudenthal's emulsion. 377 
Frisch, bacillus, of, 186 
Frontal sinus, on catheterizing the, 94 
inflammation of, 90 
Jansen's operation for em- 
pyema of, 97 
Kuhnt's operation for em- 
pyema ot. 95 
Lothrop on method of opening, 

95 
Euc's operation for empyema 

of, 98 
Ogston's operation for em- 
pyema of, 95 
Herbert Tilley's operation for 
empyema of, 98 
Fusiform bacillus of Vincent, 283 



419 



Galvanism in nasal atrophy, 69 
Galvanocautery for laryngeal neo- 
plasms, 342 
Garel and Bernand on vocal nodules, 

328 
Gargling, 272 

Gersuny on paraffin prosthesis, 179 
Gibb, J. S., on carcinoma of nose, 165 
on malignant disease of the sin- 
uses, 112 
Gleitsmann, J. W., on ethyl bromide in 

adenectomy, 231 
Gluck on laryngectomy, 359 
Goldstein's turbinal trocar, 56 
Goodale, J. L., on tonsillar abscess, 276 
Gottstein on atrophic laryngitis, 331 
definition of a mucous patch, 386 
Gouguenheim and Lombard on en- 
dolaryngeal treatment of cancer, 358 
Grabower on posticus vulnerability, 406 
Grossman on position of cords after 

section of recurrent, 406 
Griinwald on location of pain in cri- 
coarytenoid arthritis, 408 

H 

Hack on laryngeal spasm, 398 
Hager-Brand remedy for coryza, 40 
Hartmann-Kiesselbach spot on nasal j 

septum, 171 
Halsted, T. H., on chloroform in ade- 
nectomy, 230 
Hawes, Jesse, splint for fractured nose, 

147 
Hay fever, 189 
Hemophilia, 236 

Hemorrhage after adenectomy, 236 
from circumtonsillar abscess, 279 
after tonsillotomy, 252 
Heryng on laryngeal spasm, 398 

on indications for radical inter- 
ference in tuberculosis of larynx, 
381 
Hiatus semilunaris, 20 
Hilton's muscle, 310 

Hinkel, F. W., on chloroform in ade- 
nectomy, 230 
on hemorrhage after adenectomy, 
236 
Hopkins, F. F., on malignant transfor- 
mation of a nasal " myxoma," 162 
Hot air in nasal disorders, 60 
Hovell's mode of relieving odynphagia, ; 

Hume on emphysema in fracture of | 

larynx, 417 
Hydrogen peroxide in nasal atrophy, 1 

66 



Hydrops antri, 108 

Hydrorrhea, nasal, 196 

Hygienic value of voice culture. 313 

Hyperosmia, 188 

Hypertrophied tonsils, 240 

indications for use of cautery in 
removing, 247 

recurrence of, 256 
Hypnosis in hay fever, 196 
Hysterical aphonia, 393 



Incision of circumtonsillar abscess, 281 

Infundibulum, 21 

Ingals' solution of suprarenal capsule, 

194 
Intubation for laryngeal neoplasms, 342 

J 
James on spastic aphonia, 395 
Jurasz on endolaryngeal treatment of 
carcinoma, 358 

K 
Kakosmia, 188 
Keratosis, 266 

Kelly, Brown, on keratosis and my- 
cosis, 267 
on an unusual source of epis- 
taxis, 174, 
Killian's method of examining the 

larynx, 317 
Kirstein's autoscopy, 317 
Knight, F. I., on laryngeal vertigo, 394 

on trachoma of the larynx, 328 
Krause on section of recurrent nerve 

for abductor paralysis, 405 
Kuhnt on meningitis and sinus disease, 

102 
Kyle, D. B., on varieties of adenoids, 
225 



Lack, Lambert, on Woakes' theory, 152 
Lake, R., removal of epiglottis in tuber- 
culosis, 378 
on artificial turbinate of paraffin, 67 
on the treatment of tubercular 
laryngitis, 373 
Laryngeal growths, absolute alcohol in, 
344 
and adenoids, 348 
galvanocautery in, 342 
internal medication, 347 
intubation, 342, 347 

spontaneous disappearan 

.345 
thyrotomy, 348 
tracheotomy, 348 



420 



Laryngeal stridor and whistling. 398 

vertigo, 393 
Laryngitis, acute, 321 

atrophic, 331 

chronic, 325 

chronic subglottic, 330 

hemorrhagic, 321 

sicca, 331 
Laryngofissure, 347 
Laryngoscopy, 314 
Larynx, adenoma of, 340 

anatomy of, 302 

anemia of, 320 

anesthesia of, 391 

angioma of, 339 

arteries of, 310 

benign neoplasms of, 333 

carcinoma of, 351 

chorea of, 395 

cystoma of, 336 

ecchondrosis of, 339 

edema of, 3,2^ 

foreign bodies in, 409 

fibroma of, 335 

fracture of, 416 

hemorrhage of, 320 

hyperemia of, 320 

hyperesthesia of, 391 

lipoma of, 339 

muscles of, 305 

myxoma of, 337 

nerves of, 308 

neuralgia of, 392 

papilloma of, 335 

paralysis of, 400 

paresthesia of, 392 

sarcoma of, 350 

spasm of, in adults, 397 

spasm of, in children, 396 

stenosis of, in syphilis, 383 

syphilis of, 382 

tuberculosis of, 363 
Latent empyema, 83 

Lefferts, G. M., on tonsillar hemor- 
rhage, 254 

on intubation in syphilitic stenosis 
of larynx, 383 
Leland, G. A., on the treatment of 

circumtonsillar abscess, 282 
Leptothrix buccalis, 265 
Levy, R., on hypertrophy of lingual 

tonsil, 259 
Lichtwitz on latent empyema, 83 
Lingual quinsy, 261 

tonsil, hypertrophy of, 258 

varix, 260 
Luc, H., on mucocele, 108 
Luschka's bursa, 223 
Lymphatism, 224 



Lymphoid ring, 240 

M 

Mackenzie, J. N., on hay fever, 190 

on laryngectomy, 360 
Mackenzie's laryngeal forceps, method 

of using, 343 
Malignant disease of sinuses, 112 
Makuen on laryngeal whistling, 400 
Maxillary sinus (see Antrum), 76 
Mayer, Emil, on Schleich's mixture in 

adenectomy, 231 
McBride, P., on laryngeal vertigo, 394 
Medio-frontal illumination, 92 
Meschede on hysterical aphonia, 393 
Morgagni, tubercle of, 21 

ventricle of, 310 
Moure on prolapse of laryngeal ven- 
tricle, 417 
Mucin in atrophy, 65 
Mucocele, 108 
Mulberry hypertrophy, 52 
Mycosis pharyngis, 264 

N 
Nares, congenital occlusion of, 142 
Nasal fossa, angioma of, 161 

benign tumors of, 158 
chondroma of, 160 
cyst of, 160 
fibroma of, 158 
foreign bodies in, 166 
osteoma of, 160 
papilloma of, 159 
syphilis of, 176 
Xasal hydrorrhea, 196 

hypertrophy, chemical caustics in, 
57 
submucous injection in, 56 
Nasal neuroses, 188 
polypi, 150 
tampons, 59 
Nasopharyngitis, chronic, 217 
Nasopharynx, digital examination of, 
35 
fibroma of, 159 
Natier on false adenoidism, 228 
Necrosing ethmoiditis, 151 
Nerves of nasal mucous membrane, 23 
Newcomb, J. E., on fatal hemorrhage 

after adenectomy, 236 
Nichols, T. H., on the treatment of 

syphilitic adhesion of velum, 298 
Nose, anatomy of, 17 
examination of, 28 
fracture of, 146 
lupus of, 182 
malignant disease of, 165 
physiology of, 25 



421 



Nose, tuberculosis of, 183 



Odynphagia in tuberculosis, 371 
Olfaction, theory of, 26 
Onodi on anosmia, 188 
Organ of Tacobson, 21 
Osier, W., on epistaxis in telangiec- 
tasis, 169 
Ostium maxillare, 21 
Ozena, 62, 64 

and ethmoiditis, 100 

laryngis of Baginski, 331 



Pachydermia laryngis of Virchow, 326 
Padley's method in foreign bodies in 

air passages, 414 
Paraffin in deformed noses, 79, 140 

in nasal atrophy, 67 
Parosmia, 25, 188 
Paroxysmal sneezing, 189 
Pharyngeal bursa, 204 
Pharyngitis, acute, 214 

atrophic, 219 

chronic, 215 

follicular, 216 

membranous, 214 

rheumatic, 220 
Pharyngo-mycosis, 264 
Pharynx, anatomy of, 199 

anesthesia of, 299 

foreign bodies, 300 

hyperesthesia of, 299 

hypertrophy of lateral bands, 216 

lupus of, 291 

methods of examining, 206 

paralysis of, 300 

paresthesia of, 299 

spasm of, 299 

syphilis of, 292 

tuberculosis of, 289 
Polypi of antrum, no 
Pomum Adami, 302 
Priessnitz compress, 323 
Purse string ligature, 253 



Quinsy, 276 



Q 



lv 



Recurrent laryngeal paralysis, 402 
Rhinitis, acute, 36 

atrophic, 61 

caseous, 71 

chronic catarrhal, 41 

hypertrophic, 41 

membranous, 70 



Rhinitis, purulent, 71 

sicca, 63 
Rhinoliths, 167 

Rhinopharynx, adenoids in the, 222 
Rhinoscleroma, 185 
Rhinoscopy, anterior, 30 

posterior, 32 
Rhodes, J. E., on chancre of tonsil, 292 
Rice, C. C, on vocal nodules, 328 
Richards, G. L., on elongated styloid 
process as an obstacle in tonsil- 
lotomy, 250 
Rima glottidis, 310 
Roe, J. O., on foreign bodies in the 
air track, 414 
on laryngeal whistling, 400 
Rose cold, 189 

Rouge's operation for deviated septum, 
117 
for nasal sequestrum, 177 
Roughton's band, 145 



Sacculus laryngis, 310 
Schmidt, Moritz, on cancer of larynx, 
355 
on tubercular laryngitis, 375 
Schnitzler on neuralgia of the larynx, 

392 
Schroetter on dilatation of syphilitic 

stricture of larynx, 383 
Schwenn on malignant disease of the 

sinuses, 113 
Seiler's tablets, 47 

Semon, Felix, on cancer of larynx, 355 
on malignant degeneration of 
benign growths of the 
larynx, 334 
Semon's law, 406 
Sendziak, oft thyrotomy, 362 
Senn, E. J., on treatment of broken 

nose, 148 
Septum, abscess of, 140 
deviations of, 114 
ecchondrosis of, 135 
exostosis of, 136 
hematoma of, 140 
perforation of, 140 
ulceration of, 139 
Sheppegrell, W., cupric electrolysis in 
tuberculosis of larynx, 380 
a case of laryngeal cancer cured 
with X-ray, 362 
Shurly, E. L., on bacilli in tubercular 

infection, 365 
Sieur and Jacob on probing the sphe- 
noidal sinus, 105 
Simpson, W. K., on intubation in frac- 
ture of larynx, 417 



Simpson, W. K., on intubation in syph- 
ilitic stenosis of larynx, 383 
Singers' nodes, 32 
Sinusitis, acute, 73 
bacteria in, 74 
chronic, 73 
frequency of, 76 
location of pus in, 75 
relation of teeth to, 78 
traumatism as a cause of, 7; 
Smith, A. II., on monochloracetic acid 

in adhesions of velum, 298 
Smith. Harmon, on paraffin prosthesis, 

180 
Sobel and Herrman on Vincent's an- 
gina. 284 
Sommer's formula for adrenal solu- 
tion, 193 
Spastic aphonia, 395 
Sphenoidal sinus, inflammation of, 104 
sinusitis. Hinkel on hemorrhage 
after operation for, 108 
Jansen's operation for, 106 
Stanculeanu and Baup on microorgan- 
isms in sinusitis, 74 
Supralabial operation for deviated 

septum, 124 
Suprarenal extract. 174 

edema of uvula following, 213 
in hay fever, 193 
Sutherland and Lack on laryngeal 

stridor, 399 
Swain. H. L., on gargling, 273 
on lingual quinsy, 261 



Tauber, B., on a case of atrophic 

laryngitis, 331 
Thomson, St. Clair, on rheumatic 

pharyngitis, 221 
Tilley, Herbert, on papilloma of larynx 

removed under chloroform. 346 
Tongue, tumors of. 262 
Tonsillectomy, 282 
Tonsil, abscess of, 276 

benign neoplasms of, 285 

calculus of, 285 

chronic abscess of, 279 

epithelioma of, 286 

sarcoma of, 286 
Tonsils, faucial, 205 

laryngeal, 312 

lingual, 222, 258 

pharyngeal, 222 

hypertrophied, 240 

as portals of infection, 205 
Tonsilliths, 285 
i onsillitis, acute, 268 

chronic, 272 



I Tonsillitis, infectiousness of, 268 
I Tonsillotomy, anesthesia in, 254 
hemorrhage after, 247 
method of performing, 251 
results of, 256 
rash, 257 
Tornwaldt's disease, 223 
Trachoma, 328 

Transillumination of the antrum, 79 
Tubercle of Morgagni, or Zuckerkandl, 

21 
Tuberculosis of larynx, cupric electrol- 
ysis, 380 
galvanocautery in, 379 
local treatment, 373 
phototherapy in, 379 
submucous and intratracheal 

injections, 379 
surgical treatment of, 375 
Tuckey, Lloyd, on hypnosis in hay 

fever. 196 
Turbinal varix, 43 
Turbinate bodies, 24 
Turbinates, hyperemia of, 42 

hyperplasia of. 43 
Turner, Logan, anomalies of the frontal 
sinus, 92 
and Thomson on laryngeal stridor, 
399 



Ulcero-membranous angina. 283 
(Jvula, disease of, 208 

edema of, 212 

elongated, 211 
Uvulitis, 211 
L T vulotomy, 212 

V 

Vansant on hot air in nasal disorders, 
60 

Vascular collapse of turbinate, 63 

Valve of Hasner. 20 

Varix, lingual, 260 

Vegetations, adenoid, 222 

Velum, diseases of, 208 

Ventricle of the larynx, prolapse of, 
416 

Ventricular bands, function of, 312 

Vertigo, laryngeal. 393 

Vocal bands, 312 
nodules, 328 

Voltolini's sponge probang for laryn- 
geal neoplasms, 342 

W 
Waggett, Ernest, on laryngofissure 
compared with total extirpation, 361 
Waldeyer, ring of, 240 



42 3 



Walsham, W. J., on operation for col- 
lapse of nostril, 144 

Whistler on relapsing ulcerative laryn- 
gitis, 386 

Whistler's dilating laryngotome, 383 

Williams, Watson, arytenoids in an- 
chylosis and in paralysis, 408 

on cupric electrolysis in at- 
rophy, 69 

Window resection operation for de- 
viated septum, 126 

Woakes' theory of nasal polypi, 151 

Wolfenden's method of feeding in 
tuberculosis of the larynx, 371 



Wright, J., on mycosis pharyngis, 267 
on nasal polypi, 150 
on tubercle bacilli in lymphoid tis- 
sue, 206 

X 

X-rays in entering the frontal sinus, 87 
in tuberculosis, 379 



Zuckerkandl, on anomalies of the sin- 
uses, 80 
tubercle of, 21 



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